THE NATIONAL ELDER ABUSE

 INCIDENCE STUDY
 

Final Report 

September 1998 

Prepared for
 

The Administration for Children and Families and
 

The Administration on Aging
 

in The U.S. Department of Health and Human Services
 

by
 

The National Center on Elder Abuse at
 

The American Public Human Services Association*
 

in Collaboration with
 

Westat, Inc.
 

* Formerly the American Public Welfare Association 
The development of this report was supported by a grant awarded to the American Public Human 

Services Association (APHSA) jointly by the Administration for Children and Families (ACF) and the 

Administration on Aging (AoA) of the U.S. Department of Health and Human Services. The grant was a 

supplement to APHSA’s existing cooperative agreement (Grant No. 90-AM-0660) awarded by AoA to 

create the National Center on Elder Abuse (NCEA). APHSA is the lead agency for NCEA. The views 

expressed in this report are those of the authors and do not necessarily reflect the policies or views of the 

grantee organization, its subcontractor (Westat, Inc.), or the funding agencies. 
 

The National Elder Abuse Incidence Study Staff 

National Center on Elder Abuse (NCEA)
 

American Public Human Services Association (APHSA) *
 

Toshio Tatara, PhD ** 

Principal Investigator 

Lisa Blumerman Kuzmeskus, MA 

Research Analyst 

Edward Duckhorn 

Research Analyst 

Leslie Bivens 

Administrative Assistant 

Westat, Inc. 

Cynthia Thomas, PhD 

Westat Project Director 

Joseph Gertig, MA 

Field Director 

Kevin Jay 

Sentinel Recruitment 

Albert Hartley 

Programmer 

Keith Rust 

Statistician 

Joseph Croos 

Statistician 

* Formerly the American Public Welfare Association 

** Dr. Tatara retired on March 25, 1998, and Gary Cyphers, Interim NCEA Director at

 APHSA, became the National Elder Abuse Incidence Study coordinator and report 

editor. 
TABLE OF CONTENTS
 

Chapter	 Page 

EXECUTIVE SUMMARY............................................................................................. 1
 

1 INTRODUCTION ...................................................................................... 1-1
 

The Organization of this Report .................................................................... 1-3
 

2 BACKGROUND......................................................................................... 2-1
 

2.1	 Overview of the Study Design.......................................................... 2-2
 

2.2	 The Uniqueness of a Sentinel Approach ........................................... 2-3
 

3 STUDY DESIGN AND METHODS .......................................................... 3-1
 

3.1 Definitions ....................................................................................... 3-1
 

Steps in Establishing Definitions ...................................................... 3-1
 

Analysis of Current State Definitions................................. 3-1
 

Convening of Local Roundtables....................................... 3-2
 

Consensus Meeting. .......................................................... 3-2
 

Pilot Testing...................................................................... 3.2
 

Definitions of Elder Abuse, Neglect, and Exploitation ...................... 3-2
 

Physical Abuse.................................................................. 3-2
 

Sexual Abuse .................................................................... 3-3
 

Emotional or Psychological Abuse .................................... 3-3
 

Neglect .......................................................................... 3-3
 

Abandonment.................................................................... 3-3
 

Financial or Material Exploitation ..................................... 3-3
 

Self-Neglect ...................................................................... 3-3
 

3.2	 Sampling Counties, Agencies, and Sentinels..................................... 3-7
 

Sampling at the County Level............................................ 3-7
 

Sampling Sentinel Agencies Within Counties .................... 3-7
 

Sampling Sentinels Within Agencies ................................. 3-12
 

Evaluation of the Sample of Counties and the Estimates ................... 3-12
 

3.3	 Instrument Development .................................................................. 3-14
 

Pretesting Data Collection Instruments ............................................. 3-14
 

Institutional Review Board (IRB) ..................................................... 3-15
 

3.4	 APS Agency and Sentinel Agency Recruitment................................ 3-15
 

APS Recruitment.............................................................................. 3-16
 

Sentinel Agency Recruitment ........................................................... 3-16
 

Selection of Sentinels Within Agencies ............................................ 3-17
 

APS and Sentinel Agency Followup Procedures ............................... 3-18
 

Adult Protective Services and Sentinel Training ............................... 3-19
 

v 
TABLE OF CONTENTS (Continued) 

Recruitment of Alternate Sentinel Agencies...................................... 3-21
 

Sentinel Agency Refusals and Refusal Conversions.......................... 3-21
 

3.5	 Data Collection ................................................................................ 3-22
 

APS Data Collection ........................................................................ 3-22
 

Sentinel Data Collection................................................................... 3-23
 

Site Visits to APS/Aging Agencies and Sentinel Agencies................ 3-23
 

Certificates of Appreciation.............................................................. 3-25
 

Special Procedures in San Diego, California..................................... 3-25
 

3.6	 Data Receipt..................................................................................... 3-25
 

Keying ............................................................................................. 3-26
 

Coding Data Forms .......................................................................... 3-26
 

3.7	 Unduplication................................................................................... 3-27
 

3.8	 Participant Tracking ......................................................................... 3-29
 

3.9	 Weighting the Responses.................................................................. 3-29
 

PSU Base Weights ........................................................................... 3-29
 

Weighting of APS Data.................................................................... 3-30
 

Annualization................................................................................... 3-30
 

Agency Weight (non-APS Agencies)................................................ 3-30
 

Agency Nonresponse Adjustments (Sentinel Agencies) .................... 3-31
 

Sentinel Weights .............................................................................. 3-31
 

Sentinel Case-Level Weight ............................................................. 3-31
 

Weight Trimming............................................................................. 3-34

 3.10 Measuring Sampling Variability ....................................................... 3-36

 3.11 Interpreting Results in the Presence of Sampling Variability ............. 3-37
 

4 FINDINGS--INCIDENCE OF ABUSE AND NEGLECT OF THE ELDERLY 

4.1	 Comparison of Reported and Unreported Abuse and Neglect and

 Calculation of National Estimates of Abuse and Neglect.................. 4-1
 

4.2	 Abuse Reported by APS Agencies.................................................... 4-4
 

Outcomes of Investigations .............................................................. 4-4
 

Substantiated Reports of Abuse by Others ........................................ 4-7
 

Reporters of Substantiated Abuse by Others ..................................... 4-7
 

Reporters of Substantiated Reports of Self-Neglect........................... 4-8
 

Three Most Frequent Reporters for Each Maltreatment Type ............ 4-10
 

Neglect .......................................................................... 4-10
 

Emotional/Psychological Abuse ........................................ 4-10
 

vi 
TABLE OF CONTENTS (Continued) 

Financial/Material Exploitation ......................................... 4-10
 

Physical Abuse.................................................................. 4-11
 

Abandonment.................................................................... 4-11
 

Sexual Abuse .................................................................... 4-11
 

Outcomes of Investigations for Different Types of Maltreatment ...... 4-11
 

4.3 Characteristics of Elderly Victims, Reported to APS ........................ 4-13
 

Ages of Elder Abuse Victims for Selected Types of Maltreatment .... 4-13
 

Neglect .......................................................................... 4-14
 

Emotional/Psychological Abuse ........................................ 4-14
 

Physical Abuse.................................................................. 4-14
 

Financial/Material Exploitation ......................................... 4-14
 

Abandonment.................................................................... 4-14
 

Incomes of Elder Abuse Victims ...................................................... 4-15
 

Neglect .......................................................................... 4-15
 

Emotional/Psychological Abuse ........................................ 4-15
 

Physical Abuse.................................................................. 4-16
 

Financial/Material Exploitation ......................................... 4-16
 

Abandonment.................................................................... 4-16

 Sex of Elder Abuse Victims.............................................................. 4-16
 

Race/Ethnicity of Elder Abuse Victims............................................. 4-17
 

Physical and Mental Frailty .............................................................. 4-20
 

Self Care Ability ............................................................... 4-20
 

Confusion ......................................................................... 4-20
 

Depression ........................................................................ 4-21
 

4.3.1	 Characteristics of Perpetrators of Domestic Elder Abuse................... 4-22
 

Sex of Perpetrators of Elder Abuse ................................................... 4-22
 

Ages of Perpetrators of Domestic Elder Abuse ................................. 4-23
 

Race/Ethnicity of Perpetrators of Domestic Elder Abuse................... 4-26
 

Relationship of Perpetrators to Victims of Domestic Elder Abuse..... 4-28
 

4.3.2	 Characteristics of Self-Neglecting Elders.......................................... 4-30
 

Sex of Self-Neglecting Elders........................................................... 4-30
 

Age of Self-Neglecting Elders.......................................................... 4-31
 

Race/Ethnicity of Self-Neglecting Elders.......................................... 4-32
 

Self Care Ability for Self-Neglecting Elders..................................... 4-32
 

Confusion for Self-Neglecting Elders ............................................... 4-33
 

Depression for Self-Neglecting Elders.............................................. 4-33
 

4.4 Abuse Reported By Sentinel Agencies.............................................. 4-34
 

Characteristics of Elderly Victims of Non-Reported Abuse and Neglect 4-34
 

Age .......................................................................... 4-34
 

Race/Ethnicity................................................................... 4-35
 

Gender .......................................................................... 4-36
 

Income .......................................................................... 4-37
 

vii 
TABLE OF CONTENTS (Continued) 

Physical and Mental Frailty .............................................................. 4-37
 

Self Care Ability ............................................................... 4-38
 

Confusion ......................................................................... 4-38
 

Depression ........................................................................ 4-39
 

Signs of Physical and Mental Frailty for Specific forms of Abuse and
 

Neglect ...................................................................................... 4-39
 

Self Care Ability ............................................................... 4-40
 

Confusion ......................................................................... 4-40
 

Depression ........................................................................ 4-41
 

Characteristics of Perpetrators of Abuse and Neglect........................ 4-42
 

5. CONCLUSIONS......................................................................................... 5-1
 

Overview and “Iceberg” Theory.................................................................... 5-1
 

Summary of Findings.................................................................................... 5-4
 

Limitations of NEAIS Research.................................................................... 5-6
 

Implications of NEAIS Findings ................................................................... 5-7
 

Future Research Questions and Issues........................................................... 5-9
 

Conclusion ................................................................................................... 5-10
 

REFERENCES 

viii 
TABLE OF CONTENTS (Continued) 

LIST OF APPENDICES 

Appendix 

A TECHNICAL BREAKDOWN OF STATE ELDER ABUSE DEFINITIONS 

B ROUNDTABLE OF ELDER ABUSE PROFESSIONALS 

C ADVISORY COMMITTEE MEETING 

D SAMPLING PLAN 

E APS AND SENTINEL TRAINING MATERIALS 

F IRB/CERTIFICATE OF CONFIDENTIALITY 

G LOCATION OF APS PROGRAM OR AGENCY IN STATES 

H APS RECRUITMENT MATERIALS 

I SENTINEL RECRUITMENT MATERIALS 

J SITE VISIT INFORMATION 

K DATA COLLECTION CLOSURE 

L WEIGHTING PLAN 

M TABLES SHOWING STANDARD ERRORS 

ix 
TABLE OF CONTENTS (Continued) 

LIST OF TABLES 

Table Page
 

3-1 Signs and symptoms of abuse and neglect .......................................................... 3-4
 

3-2 Sampled counties for the national elder abuse incidence study............................ 3-9
 

3-3 Sentinel agency allocation by agency type.......................................................... 3-11
 

3-4 NEAIS annualized national estimates from APS data in 20 counties by region
 

compared to NCEA's Survey of Domestic Elder Abuse Reports
 

(duplicated totals) .............................................................................................. 3-13
 

3-5 APS and sentinel agency pretest dates and number of forms received ................. 3-15
 

3-6 Sentinel participation status, by agency type....................................................... 3-18
 

3-7 Participation status, by agency type.................................................................... 3-22
 

3-8 APHSA site visits to APS agencies .................................................................... 3-24
 

3-9 Westat site visits to sentinel agencies ................................................................. 3-24
 

3-10 Aggregate sentinel case-level weights by PSU and agency type.......................... 3-32
 

3-11 Aggregate weights attached to sentinel forms after weight trimming................... 3-35
 

4-1 National incidence of abuse, neglect, and self-neglect of persons 60 years and older,
 

1996 (unduplicated) ........................................................................................... 4-2
 

4-2 Types of elder maltreatment substantiated by APS agencies .............................. 4-7
 

4-3 Reporters of substantiated abuse by others ......................................................... 4-8
 

4-4 Reporters of substantiated reports of self-neglect................................................ 4-9
 

4-5 Three most frequent reporters for each maltreatment type................................... 4-10
 

4-6 Outcomes of investigations for different types of maltreatment........................... 4-12
 

4-7 Incomes of elder abuse victims for selected types of maltreatment...................... 4-15
 

4-8 Ability to Care for Self Physically (APS) ........................................................... 4-20
 

4-9 Confusion (APS)................................................................................................ 4-21
 

x 
TABLE OF CONTENTS (Continued) 

LIST OF TABLES (Continued) 

Table Page
 

4-10 Depression (APS) .............................................................................................. 4-21
 

4-11 Sex of perpetrators of domestic elder abuse for selected types of
 

maltreatment...................................................................................................... 4-23
 

4-12 Age of perpetrators of domestic elder abuse for selected types of
 

maltreatment...................................................................................................... 4-24
 

4-13 Race/ethnicity of perpetrators of domestic elder abuse for selected
 

types of maltreatment......................................................................................... 4-27
 

4-14 Relationship of perpetrators to victims of domestic elder abuse for
 

selected types of maltreatment............................................................................ 4-29
 

4-15 Self-Neglecting Elders -- Ability to Care for Self Physically (APS).................... 4-33
 

4-16 Self-Neglecting Elders – Confusion (APS)......................................................... 4-33
 

4-17 Self-Neglecting Elders – Depression (APS)........................................................ 4-34
 

4-18 Type of abuse, by age: Percentages (Sentinel) ................................................... 4-35
 

4-19 Type of abuse, by minority status: Percentages (Sentinel).................................. 4-36
 

4-20 Type of abuse, by gender: Percentages (Sentinel) .............................................. 4-36
 

4-21 Ability to Care for Self Physically (Sentinel)...................................................... 4-38
 

4-22 Confusion (Sentinel) ......................................................................................... 4-39
 

4-23 Depression (Sentinel)......................................................................................... 4-39
 

4-24 Ability to Care for Self Physically by Type of Abuse (Sentinel) ......................... 4-40
 

4-25 Confusion by Type of Abuse (Sentinel).............................................................. 4-41
 

4-26 Depression by Type of Abuse (Sentinel)............................................................. 4-41
 

4-27 Relationship of alleged perpetrators of abuse for sentinel data ............................ 4-43
 

4-28 Characteristics of alleged perpetrators of abuse for sentinel data......................... 4-44
 

xi 
TABLE OF CONTENTS (Continued) 

LIST OF FIGURES 

Figure Page
 

ES-1 Iceberg theory showing NEAIS identified unreported abuse and neglect, excluding
 

self-neglect ........................................................................................................ ES-17
 

2-1 Iceberg theory of elder abuse.............................................................................. 2-4
 

3-1 States by OBE region, with participating NEAIS states in gray........................... 3-8
 

3-2 Start and stop dates for each participating county ............................................... 3-19
 

3-3 Duplicated and unduplicated APS and sentinel reports ....................................... 3-28
 

4-1 Outcomes of APS investigations of domestic elder abuse, neglect, and self-neglect
 

reports ............................................................................................................... 4-5
 

4-2 Substantiated and unsubstantiated reports to APS/aging agencies by
 

OBE region........................................................................................................ 4-6
 

4-3 Ages of elder abuse victims for selected types of maltreatment........................... 4-13
 

4-4 Sex of elder abuse victims for selected types of maltreatment............................. 4-17
 

4-5 Race/ethnicity of elder abuse victims for selected types of maltreatment............. 4-19
 

4-6. Sex of perpetrators of elder abuse....................................................................... 4-22
 

4-7 Ages of perpetrators of domestic elder abuse...................................................... 4-24
 

4-8 Race/ethnicity of perpetrators of domestic elder abuse........................................ 4-26
 

4-9 Relationship of perpetrators to victims of domestic abuse................................... 4-28
 

4-10. Sex of self-neglecting elders .............................................................................. 4-30
 

4-11 Age of self-neglecting elders.............................................................................. 4-31
 

4-12 Race/ethnicity of self-neglecting elders .............................................................. 4-32
 

5-1 Iceberg theory showing NEAIS identified unreported abuse and neglect, excluding
 

self-neglect ........................................................................................................ 5-4
 

xii 
The National Elder Abuse Incidence Study 

Executive Summary 

Introduction and Background 

America’s burgeoning elder population has affected every segment of the social, political, 

and economic landscape. Public debate of the issues surrounding the special needs of the approximately 

44 million persons in this country age 60 years and over has heightened national awareness and concern. 

As a result, public policies relating to issues such as retirement security, affordable long-term care, and 

quality of life are changing to meet the unique needs of the aging population. Yet, as the public looks 

toward improving the lives of the elderly, abuse and neglect of elders living in their own homes have 

gone largely unidentified and unnoticed. The National Elder Abuse Incidence Study has shed new light on 

this significant problem with the finding that approximately 450,000 elderly persons in domestic 

settings were abused and/or neglected during 1996. When elderly persons who experienced selfneglect are added, the number increases to approximately 551,000 in 1996. Additionally, through 

this study we have learned that: 

•	 Female elders are abused at a higher rate than males, after accounting for their larger 

proportion in the aging population. 

•	 Our oldest elders (80 years and over) are abused and neglected at two to three times their 

proportion of the elderly population. 

•	 In almost 90 percent of the elder abuse and neglect incidents with a known perpetrator, the 

perpetrator is a family member, and two-thirds of the perpetrators are adult children or 

spouses. 

•	 Victims of self-neglect are usually depressed, confused, or extremely frail. 

The National Elder Abuse Incidence Study (NEAIS) was conducted by the National Center 

on Elder Abuse at the American Public Human Services Association (formally known as the American 

Public Welfare Association) and the Maryland-based social science and survey research firm, Westat. 

The Administration for Children and Families (ACF) and the Administration on Aging (AoA) in the U.S. 

Department of Health and Human Services jointly funded this research. The study asked the fundamental 

1
 Executive Summary
 
question: What is the incidence of domestic elder abuse and neglect in the United States today? In 

public health and social research, the term “incidence” means the number of new cases occurring over a 

specific time period. The NEAIS used a rigorous methodology to collect national incidence data on what 

has been a largely undocumented phenomenon, and it provides the basis to estimate the incidence of 

domestic elder abuse and neglect among those aged 60 and above in 1996. 

The NEAIS originated in 1992 when Congress, through the Family Violence Prevention and 

Services Act of 1992 (P.L. 102-295), directed that a study of the national incidence of abuse, neglect, and 

exploitation of elderly persons be conducted under the auspices of the Administration for Children and 

Families. ACF consulted with the federal Administration on Aging, resulting in the two agencies 

combining resources and expertise to support the national study. Because the legislative mandate 

primarily was concerned with the prevention of violence in domestic settings, the study focused only on 

the maltreatment of non-institutionalized elderly. Elders living in hospitals, nursing homes, assistedliving facilities, or other institutional or group facilities were not included in the study.

 In order to maximize the utility of the research, the study also collected and analyzed data 

about elder self-neglect in domestic settings, and these findings are reported separately from the findings 

for abuse and neglect. In the NEAIS, the phrase “elder maltreatment” generally refers to the seven types 

of abuse and neglect that are measured in the study—physical abuse, sexual abuse, emotional or 

psychological abuse, financial or material exploitation, abandonment, neglect, and self-neglect. An early 

task of the NEAIS was to develop standardized definitions for each specific type of abuse and neglect, 

which are provided later in this executive summary. 

Prior attempts to generate national data on domestic elder abuse in the United States relied 

on state-compiled statistics of suspected abuse, with considerable variations in definitions and 

comprehensiveness of reporting systems. These earlier studies, frequently designed to estimate the 

prevalence (i.e., the total number of cases at a designated time period) of elder abuse rather than the 

incidence (i.e., the new cases occurring over a specific period of time), varied considerably in their 

research questions, methodology, sources of data, analysis, and findings. Accordingly, comparisons of 

earlier research with the NEAIS findings should be done cautiously. 

2
 Executive Summary
 
 

 

The NEAIS gathered data on domestic elder abuse, neglect, and self-neglect through a 

nationally representative sample of 20 counties in 15 states. For each county sampled, the study collected 

data from two sources: (1) reports from the local Adult Protective Services (APS) agency responsible for 

receiving and investigating reports in each county: and (2) reports from “sentinels”—specially trained 

individuals in a variety of community agencies having frequent contact with the elderly. The NEAIS 

study design and methods are described more fully later in this Executive Summary. 

The NEAIS research is groundbreaking because it provides, for the first time, national 

incidence estimates of elder abuse, which can serve as a baseline for future research and service 

interventions in this critical problem. Its findings confirm some commonly held theories about elder 

abuse and neglect, notably that officially reported cases of abuse are only the “tip of the iceberg,” or a 

partial measure of a much larger, unidentified problem. The NEAIS final report offers insight into critical 

questions, including: who are the victims of elder abuse and neglect, and who are the perpetrators? Who 

are the reporters of abuse and neglect? What are the characteristics of self-neglecting elders? What is the 

extent of the problem of abuse, neglect, and self-neglect in our communities and what forms do they 

take? 

National Elder Abuse Incidence Estimates 

To arrive at the most accurate estimate of the national incidence of elder abuse and neglect 

in 1996, researchers added two numbers: (1) reports submitted to APS agencies and substantiated (i.e., 

determined to have occurred or be occurring) by those agencies, and (2) reports made by sentinels and 

presumed to be substantiated. Consistent with three national incidence studies on child abuse and neglect, 

this methodology assumes the sentinel reports represent substantiated reports. Because the incidence 

estimate is statistically derived from the nationally representative sample, researchers also calculated the 

standard error to establish the range of the incidence estimate within a 95 percent confidence interval.1 

Using the identical methodology, researchers also separately calculated the estimated 

national incidence of elder abuse, neglect, and/or self-neglect in 1996. Both incidence estimates are for 

unduplicated elderly persons. In other words, individuals are counted only once, even if: (1) they were 

1 The standard error of the estimates of APS agencies is relatively low because of the large number of actual reports (1,466) by those agencies in 

the sample, while the standard error for the sentinel data is relatively large because of the smaller number of reports (140) in the study sample. 

The range of the “true” value, at the 95 percent confidence level, for an estimated number is plus and minus two times the standard error. 

3
 Executive Summary
 
abused and neglected and/or self-neglecting, (2) more than one report were received about the same 

incident, or (3) different incidents were reported for the same elderly person during the study period. 

Estimated Incidence of Elder Abuse and/or Neglect in 1996 

The best national estimate is that a total of 449,924 elderly persons, aged 60 and over, 

experienced abuse and/or neglect in domestic settings in 1996. Of this total, 70,942 (16 percent) were 

reported to and substantiated by APS agencies, but the remaining 378,982 (84 percent) were not reported 

to APS. From these figures, one can conclude that over five times as many new incidents of abuse and 

neglect were unreported than those that were reported to and substantiated by APS agencies in 1996. The 

standard error suggests that nationwide as many as 688,948 elders or as few as 210,900 elders could have 

been victims of abuse and/or neglect in domestic settings in 1996. 

Estimated Incidence of
 

Elder Abuse, Neglect, and/or Self-Neglect in 1996
 

The best national estimate is that a total of 551,011 elderly persons, aged 60 and over, 

experienced abuse, neglect, and/or self-neglect in domestic settings in 1996. Of this total, 115,110 (21 

percent) were reported to and substantiated by APS agencies, with the remaining 435,901 (79 percent) not 

being reported to APS agencies. One can conclude from these figures that almost four times as many new 

incidents of elder abuse, neglect, and/or self-neglect were unreported than those that were reported to and 

substantiated by APS agencies in 1996. The standard error suggests that nationwide as many as 787,027 

elders or as few as 314,995 elders could have been abused, neglected, and/or self-neglecting in domestic 

settings in 1996. 

4
 Executive Summary
 
Abuse and Neglect Reported by APS Agencies 

Characteristics of Victims of Domestic Elder Abuse 

Of 236,479 reports of abuse, neglect, and self-neglect to APS in 1996, 48.7 percent, or 

115,110 reports were substantiated after investigation, 39.3 percent were unsubstantiated, and 8.2 

percent were still under investigation at the end of 1996. The remaining 3.8 percent of reports had other 

outcomes (e.g., suspected victim died, could not be located, or had moved away). 

Of the 115,110 substantiated reports in 1996 for which information was available, 61.6 

percent (70,942) were reports of incidents in which elders were maltreated by other people (also called 

“perpetrators”), while the remaining 38.4 percent (44,168) were incidents of self-neglecting elders. Of 

the 70,942 unduplicated substantiated reports of elder abuse attributable to perpetrators (which excludes 

self-neglect), the most common types were: neglect (34,525), emotional/ psychological abuse (25,142), 

financial/material exploitation (21,427), and physical abuse (18,144). 

While the substantiation rate for all types of investigations of elder abuse combined was 48.7 

percent, the substantiation rates for different types of maltreatment varied considerably, as follows: 

physical abuse—61.9 percent; abandonment—56.0 percent; emotional/psychological abuse—54.1 

percent; financial/material abuse—44.5 percent; and neglect—41.0 percent. (The substantiation rate for 

sexual abuse was not statistically significant.) 

A wide variety of reporters of domestic elder abuse were found in the 70,942 substantiated 

reports of abuse and neglect. The most frequent reporters were family members, who were responsible 

for 20.0 percent of all reports, followed by hospitals (17.3 percent), and police and sheriffs (11.3 percent). 

In-home service providers, friends/neighbors, and physician/nurses/clinics each reported between 8 and 

10 percent of total reports. The remaining reports were made by out-of-home service providers, banks, 

public health departments, and other reporters. 

Hospitals (19.8 percent) and friends/neighbors (19.1 percent) were the most frequent 

reporters of substantiated reports of self-neglect in 1996. Police/sheriff, in-home service providers, 

and physicians/nurses/clinics each reported 12 percent of total reports. Out-of-home providers, family 

members, banks, the victims themselves, and other reporters made the remaining reports. 

5
 Executive Summary
 
 

The report examines the age of victims of different types of abuse reported to APS. The 

oldest elders (those over 80 years of age), who made up about 19 percent of the U.S. elderly population in 

1996, were far more likely to be the victims of all categories of abuse, with the exception of 

abandonment. They accounted for over half the reports of neglect (51.8 percent), and 48.0 percent of 

financial/material abuse, 43.7 percent of physical abuse, and 41.3 percent of emotional/psychological 

abuse. In all types of abuse and neglect, elderly victims in the 60–64 and 65–69 age groups accounted for 

the smallest percentages. 

Female elders were more likely to be the victims of all categories of abuse, except for 

abandonment. While making up about 58 percent of the total national elderly population in 1996, women 

were the victims in 76.3 percent of emotional/psychological abuse, 71.4 percent of physical abuse, 63.0 

percent of financial/material exploitation, and 60.0 percent of neglect, which was the most frequent type 

of maltreatment. A majority of the victims of abandonment were men (62.2 percent). 

In 1996, white elders were 84.0 percent of the total elder population, while black elders 

comprised 8.3 percent, and Hispanic elders were 5.1 percent. While white elders were the victims in 

eight out of ten reports for most types of maltreatment, black elders were over-represented in neglect 

(17.2 percent), financial/material exploitation (15.4 percent), and emotional/psychological abuse (14.1 

percent). Hispanic elders and those from other racial/ethnic groups were under-represented among 

victims in all types of maltreatment. 

The study found that elders who are unable to care for themselves were more likely to 

suffer from abuse. Approximately one-half (47.9 percent) of the substantiated incidents of elder abuse 

involved elderly persons who were not able to care for themselves, 28.7 percent were somewhat able to 

do so, and 22.9 percent were able to care for themselves. For the national elderly population as a whole, 

the federal government estimates that 14 percent have difficulties with one or more activities of daily 

living.2 

Approximately six out of ten substantiated elder abuse victims experienced some degree of 

confusion (31.6 percent were very confused, or disoriented, and 27.9 percent were sometimes confused). 

This represents a high degree of potential mental impairment among this group of abused elders, 

particularly when compared with the estimated 10 percent of the total national elderly population 

suffering with some form of dementia. 

2 Nov. 1997 U.S. Census Bureau report on disability status of persons 65 years and older in 1994-95. 

6
 Executive Summary
 
About 44 percent of all substantiated abused elders were gauged to be depressed at some 

level, with about 6 percent of them severely depressed. This compares with the estimated 15 percent of 

all elders nationally who are depressed at any one time. One-third of substantiated elder abuse victims 

(35.4 percent) displayed no signs of depression. 

Characteristics of Perpetrators of Domestic Elder Abuse 

Overall, men were the perpetrators of abuse and neglect 52.5 percent of the time. Of the 

substantiated cases of abuse and neglect, males were the most frequent perpetrators for abandonment 

(83.4 percent), physical abuse (62.6 percent), emotional abuse (60.1 percent) and financial/material 

exploitation (59.0 percent). Only in cases of neglect were women slightly more frequent (52.4 percent) 

perpetrators than men. 

The age category with the most perpetrators was the 41 to 59 age group (38.4 percent), 

followed by those in the 40 years or less group who were perpetrators in more than one quarter of reports 

(27.4 percent). About one-third of perpetrators (34.3 percent) were elderly persons themselves (60 and 

over). Perpetrators of financial/material exploitation were particularly younger compared to other types 

of abuse, with 45.1 percent being 40 or younger and another 39.5 percent being 41–59 years old. Eightyfive percent of the perpetrators of financial/material exploitation were under age 60. 

About three-fourths (77.4 percent) of domestic elder abuse perpetrators in 1996 were white, 

and less than one-fifth (17.9 percent) were black. Other minority groups accounted for only 2 percent of 

the perpetrators, while the race of 2.7 percent of perpetrators was unknown. 

Data show that family members were the perpetrators in nine out of ten (89.7 percent) 

substantiated incidents of domestic elder abuse and neglect. Adult children of elder abuse victims were 

the most likely perpetrators of substantiated maltreatment (47.3 percent). Spouses represented the second 

largest group of perpetrators (19.3 percent). In addition, other relatives and grandchildren, at 8.8 percent 

and 8.6 percent respectively, were the next largest groups of perpetrators. Non-family perpetrators 

included friends/neighbors (6.2 percent), in-home service providers (2.8 percent), and out-of home service 

providers (1.4 percent). The report provides details about the relationship of perpetrators to the victims 

for the different types of maltreatment. 

7
 Executive Summary
 
 

 

Characteristics of Self-Neglecting Elders 

Self-neglect was included in the NEAIS and a common definition and signs and symptoms 

were adopted for it, as with all the specific types of abuse and neglect. Self-neglect is characterized as the 

behaviors of an elderly person that threaten his/her own health or safety. Self-neglect generally manifests 

itself in an older person’s refusal or failure to provide himself or herself with adequate food, water, 

clothing, shelter, safety, personal hygiene, and medication (when indicated).3 

Approximately two-thirds (65.3 percent) of substantiated self-neglecting elders were female, 

compared with women being 58 percent of the overall elderly population. About two-thirds (65.1 

percent) of self-neglecting elders were 75 years or older (or almost twice their proportion of the overall 

elderly). The largest proportion of self-neglecting elders were in the oldest age category of 80 and over 

(44.7 percent), while the proportion decreased in each declining age group, with only 6.3 percent of selfneglecting elders being in the 60–64 year age group (compared to their being 23 percent of the total 

elderly population). 

Self-neglecting elders were predominately white (77.4 percent), while 20.9 percent were 

black and 1.7 percent were other or unknown. The black elderly are two-and-a-half times more likely to 

be self-neglecting than their proportion of the elderly population. 

Not surprisingly, most (93.3 percent) self-neglecting elders have difficulty caring for 

themselves. Of these elders, 34.3 percent are not capable of caring for themselves, while 59.0 percent are 

somewhat able to care for themselves. Three out of ten self-neglecting elders (29.9 percent) are very 

confused or disoriented, while 45.4 percent are sometimes confused. Three-quarters (75.3 percent) of 

substantiated self-neglecting elders suffer from some degree of confusion. 

Abuse and Neglect Reported by Sentinel Agencies 

The remaining findings from the NEAIS address elder abuse reported by 1,156 sentinel 

reporters in the 248 sentinel agencies. Since sentinel data are not officially reported to the APS agencies, 

they are not officially substantiated. Sentinels were, however, carefully trained to screen out incidents 

For purposes of this study, the definition of “self-neglect” excludes a situation in which a mentally competent older person (who understands 

the consequences of her/his decisions) makes a conscious and voluntary decision to engage in acts that threaten her/his health or safety. 

8
 Executive Summary
 

3
that would not be supported. The unduplicated sentinel reports were relatively small in number (140) 

and, therefore, standard errors are relatively high. 

Characteristics of Elderly Victims of Nonreported Domestic Abuse and Neglect 

(Sentinel) 

Neglect was highest among those 80 years and over (60.0 percent). Physical, emotional, and 

financial abuse were found at higher rates among those aged 60 to 70 than among those 80 and older. 

As with APS reports, a majority of victims of all types of abuse were women, as reported by 

sentinels. Although women represented about 58 percent of the total U.S. elderly population in 1996, 

over 80 percent of the physical abuse recognized by sentinels, over 90 percent of the financial abuse, over 

70 percent of the emotional abuse, and over 65 percent of the neglect cases was found among women 

rather than men. Abandonment was also more frequent for women (65.4 percent), in contrast to 

substantiated APS reports, which show men were more likely to be abandoned (62.2 percent). 

The data do not show that rates of unreported abuse and neglect are higher among minorities 

than among nonminorities. Rather, minorities, which collectively accounted for 15.5 percent of the total 

elderly population in 1996, were victims of abuse, as reported by sentinels, between 3.6 and 7.6 percent 

depending on the type of abuse. 

Data from sentinel reports reveal that only one-third (33.8 percent) of the victims were able 

to care for themselves, another one-third (33.1 percent) were somewhat able to care for themselves, and 

18.8 percent were not able to care for themselves. (Sentinels were unable to make a determination 14.2 

percent of the time.) Individuals experiencing neglect, abandonment, and self-neglect were most often 

reported by sentinels as not able or only somewhat able to care for themselves. Two-thirds (67.7 percent) 

of those that were physically abused were thought to have the ability to care for themselves, suggesting 

that such abuse is not perpetrated on just the most vulnerable individuals. 

Sentinels reported, through observation not diagnosis, that over one-third (36.6 percent) of 

alleged victims were not confused, about an equal proportion (37.9 percent) were sometimes confused, 

and a relatively small percentage (7.5 percent) were very confused or disoriented. Sentinels were unable 

9
 Executive Summary
 
to make one of these choices 18.0 percent of the time. Confusion was most common among those who 

experienced neglect, abandonment, and self-neglect. 

In noting observations of depression, sentinels were unable to make a determination for a 

third of the elders they saw. Sentinel data show that 20.0 percent of the alleged victims were not 

depressed, 41.4 percent seemed to be moderately depressed, and a relatively small proportion (5.5 

percent) appeared severely depressed. Signs and symptoms of moderate or severe depression were 

relatively high across all forms of abuse and neglect, but did not stand out for any one category when 

standard errors are taken into account. 

Characteristics of Perpetrators of Nonreported Abuse and Neglect (Sentinel) 

As with APS reports, perpetrators reported by sentinels were most frequently family 

members (89.6 percent), including the adult children (30.8 percent), spouses (30.3 percent), and a parent 

(24.0 percent). Parents are possible abusers of elders because elders were defined as persons aged 60 and 

over, and some persons in their 60s and 70s had parents in their late 70s and 80s. 

Friends, neighbors, and service providers were believed to be responsible for the abuse and 

neglect 10 percent of the time. 

The most common age range for perpetrators was the middle years, ages 36 to 59 (45.5 

percent), with 28.6 percent of abuse being committed by people 60 and older, and 15.3 percent by those 

35 and younger. 

Nearly twice as many men as women were reported as perpetrators of abuse and neglect by 

sentinels (63.1 percent compared to 35.4 percent). 

NEAIS Study Design and Methods 

The National Elder Abuse Incidence Study gathered data on domestic elder abuse, neglect, 

and self-neglect through a nationally representative sample of 20 counties. For each county sampled, the 

study collected data from two sources: (1) reports from the local Adult Protective Service (APS) agency 

10
 Executive Summary
 
responsible for receiving and investigating reports in each county; and (2) reports from approximately 

1,100 “sentinels”—specially trained individuals in a variety of community agencies having frequent 

contact with the elderly. Many sentinels were mandatory or voluntary reporters of elder abuse, as defined 

by state laws. The sentinel approach to collecting data is an alternative to more costly general population 

surveys and has been used successfully in all three National Incidence Studies of Child Abuse 

commissioned by the federal government. This method was pioneered nearly 20 years ago by Westat, 

APHSA’s collaborative partner for the NEAIS study, in the nation’s first-ever incidence study on child 

abuse. The approach is based upon the hypothesis that officially reported cases of abuse represent only a 

small proportion of actual episodes of abuse in the community. 

Establishing Definitions 

Historically, a major impediment to collecting uniform data on elder maltreatment nationally 

has been a lack of comparability of definitions of abuse, neglect, and exploitation. In addition to 

differences among states, recognized elder experts themselves continue to disagree on definitions. 

Accordingly, the first task of NEAIS was to develop standardized definitions of elder maltreatment, thus 

ensuring greater comparability and reliability of results. The process involved several steps: 

•	 Analysis of Current State Definitions—The existing state laws defining abuse, neglect, and 

exploitation were compiled and analyzed for all states and territories, and the most common 

components of the definitions across states were selected as potential definitions. 

•	 Convening of Local Roundtables—Two roundtables of representative local professionals who 

deal with elder abuse, neglect, and exploitation were convened to obtain firsthand, 

community-level information on how elder abuse is detected, reported, and investigated, 

which aided in the development of the standardized definitions. 

•	 Consensus Meeting—A group of elder abuse experts and researchers, including NCEA and 

NEAIS advisory committee members, provided an in-depth analysis of the draft definitions 

and revised and prepared them for pilot-testing. The final definitions included: 

•	 Physical abuse was defined as the use of physical force that may result in bodily 

injury, physical pain, or impairment. Physical punishments of any kind were 

examples of physical abuse. 

� Sexual abuse was defined as non-consensual sexual contact of any kind with 

an elderly person. 

� Emotional or psychological abuse was defined as the infliction of anguish, 

pain, or distress. 

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 Executive Summary
 
� Financial or material exploitation was defined as the illegal or improper 

use of an elder’s funds, property, or assets. 

� Abandonment was defined as the desertion of an elderly person by an 

individual who had physical custody or otherwise had assumed responsibility 

for providing care for an elder or by a person with physical custody of an 

elder. 

� Neglect was defined as the refusal or failure to fulfill any part of a person’s 

obligations or duties to an elder. 

� Self-neglect was characterized as the behaviors of an elderly person that 

threaten his/her own health or safety. The definition of self-neglect excludes 

a situation in which a mentally competent older person (who understands the 

consequences of his/her decisions) makes a conscious and voluntary decision 

to engage in acts that threaten his/her health or safety. 

•	 Pilot-Testing—Two Adult Protective Services agencies and seven local sentinel agencies (in 

the Washington, D.C., area, but not involved in the study) field pilot-tested the definitions 

and data collection instruments, which were revised based on the results of the tests. (The 

full definition and signs and symptoms for each type of abuse and neglect are provided in 

detail in the full report.) 

Sampling Counties and Evaluation of Sample 

NEAIS employed a stratified, multistage sample of 20 nationally representative counties, 

selected with probability proportional to the number of elders living in these areas. The counties were 

stratified by five variables: geographic region, metropolitan area, elder abuse reporting requirements 

(mandatory and nonmandatory), percentage of elders, and percentage of poor elders. The use of the 

probability proportional to size method ensures an approximately self-weighting sample—that is, every 

abused elder in the county has approximately the same chance of being identified, regardless of location, 

when the measure of size is the number of elders in the county. This methodology produced a sample of 

20 counties in 15 states, with five counties in each of the four major geographic regions of the country. 

The sample also was reflective of the other four stratification variables. 

Because the sample was based on 20 out of about 3,000 counties in the country, it was 

important to examine the accuracy of the elder abuse estimates using outside sources, to the extent 

possible. The National Center on Elder Abuse (NCEA), in spring 1997, conducted A Survey of State APS 

and Aging Agencies on Domestic Abuse for FY 95 and 96. All states shared counts of all domestic elder 

abuse reports to state report-receiving agencies and these data were compiled to be comparable to that 

12
 Executive Summary
 
collected by the NEAIS. Using rigorous estimation methods, data were weighted to represent national 

totals and annualized. The numbers of cases in the data obtained from the states by NCEA were very 

close to the NEAIS national estimates. The total number of actual reports obtained from the states by 

NCEA was only 1.4 percent greater than the NEAIS estimated total. The statistical procedures used to 

produce the national estimates in this NEAIS appear to be extremely accurate. 

Sampling Sentinel Agencies and Sentinels 

One of the most important elements of the NEAIS was the selection of four types of 

community agencies from which community sentinels would be selected: law enforcement agencies 

(sheriff’s departments and municipal police departments); hospitals (including public health departments); 

elder care providers (adult day care centers, senior centers, and home health care agencies); financial 

institutions (banks). Using the best sources of agency listings for each sentinel type, a sample was drawn 

for each of the 20 sampled counties, usually averaging 12–13 agencies per county. Two banks per county 

were selected to ensure that possible incidents of financial exploitation of elders would be identified. The 

remaining agencies were distributed among the other categories of agencies proportional to the number of 

agencies available in each county, resulting in a total of 248 sentinel agencies in the 20 counties 

participating in the study. 

A rigorous methodology was used to select the actual sentinels within the designated sentinel 

agencies. To be eligible, individuals had to have frequent contact with the elderly and had to be able to 

identify abuse if they encountered it. A computer software program was used to randomly pick every nth 

sentinel from a roster of eligible sentinel candidates provided by the agency. The number of sentinels 

selected per agency was typically four to six, with a total of about 50 sentinels per county. This resulted 

in a total of 1,158 sentinels participating in the study across the 20 counties. 

The designation of Adult Protective Services (APS) agencies, on the other hand, is made by 

each state, and the designated agency varies by state. For the 20 sampled counties, the distribution of 

APS agencies participating in the study were: 10 in the state human services agency; six in the state unit 

on aging, but within the human services agency; and four in the state unit on aging and outside the human 

services agency. 

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 Executive Summary
 
Data Forms and Training 

The data collection forms for both the APS caseworkers and sentinel agency staff were 

designed to be easy to complete and to require as few references as possible to other documents. As with 

the abuse and neglect definitions, several versions of the instruments were extensively pilot-tested with 

local APS and service agency staff. The APS and sentinel data forms were identical with two exceptions: 

the APS instrument included sections for documenting the source of the report to the agency and for the 

disposition of the case following investigation (i.e., substantiated or unsubstantiated), while the sentinel 

forms did not. 

In order to increase valid and reliable reporting across all 20 counties, an innovative 

approach was developed for training sentinels and APS agency personnel using a specially designed 

participant guide book and instructional videos. The training focused on identifying elder abuse 

according to the standardized definitions and related signs and symptoms, and recording data on the 

specially designed forms. Additionally, an “800” telephone number was available for APS and sentinel 

participants to call study staff with any questions about data collection procedures or client eligibility. 

Data Collection, Receipt, and Management 

Sentinel and APS data collection took place over an eight-week period. Starting in January 

1996, all reporters in one or two counties started data collection each month, according to a preset 

schedule. Staggering reporting periods throughout this 12-month period (calendar year 1996) allowed the 

study to account for possible seasonal variations that might occur in elder abuse. 

Sentinel data collection procedures were similar to APS agencies; however, sentinels were 

asked to forward reports of suspected cases of elder abuse to the NEAIS research staff as soon as possible 

after observing the suspected abuse. To encourage candid, confidential reporting, the designated 

coordinator in each sentinel agency did not review or edit forms completed by the individual sentinels. 

Sentinels also did not attempt to substantiate incidents of abuse. Sentinels, however, were carefully 

trained to screen out incidents that would not be supported as elder abuse or neglect. In contrast, all 

reports of suspected abuse received by the APS agencies were investigated and a determination of 

substantiation or nonsubstantiation made, as required by the laws of each state. It should be noted, 

however, that an APS agency’s determination of nonsubstantiation of a report of abuse or neglect does 

14
 Executive Summary
 
not mean conclusively that abuse or neglect did not happen. Rather, nonsubstantiation of a report can 

mean that the level of proof required by that state was not met, despite indications that abuse or neglect 

may have occurred. 

NEAIS staff received and reviewed all submitted data collection forms for completeness and 

called the sending agency coordinators to discuss any missing or unclear data. Both APS and sentinel 

data forms required respondents to provide a brief narrative describing the maltreatment events. This 

maltreatment information was evaluated according to the study definitions and eligibility criteria, and 

reports that did not meet the study definitions were excluded from the database (e.g., victim lived in 

institutional setting; incident not based on common definitions). 

Unduplication 

The formal process of eliminating duplication in survey research data is called 

“unduplication.” The NEAIS was interested in determining the number of new unduplicated elderly 

persons who were abused or neglected during 1996 in order to arrive at estimates of reported and 

unreported abuse and neglect. Sometimes more than one data form was received for the same maltreated 

elder, describing either the same or different abusive incidents. It was necessary to identify such 

duplicates and count each person only once for purposes of this study. Out of a total of 1,699 APS and 

sentinel reports, study staff identified 93 sets of genuine duplicates, resulting in 1,606 unduplicated 

reports (1,466 APS and 140 sentinel). Duplicate cases reported both to APS and sentinel agencies were 

removed from the sentinel data file, so that duplicated instances of abuse and neglect were counted as 

reports to APS. Duplicate sentinel reports were assigned to the sentinel agency that first sent in the form. 

Obtaining National Estimates from the Study Data 

The samples of agencies and sentinels who participated in the NEAIS were selected using 

scientific probability sampling methods to obtain a nationally representative sample. As a result, it is 

possible to make valid projections from the NEAIS data, to make national estimates of the numbers of 

elders who have been abused and neglected, and to describe their characteristics. 

15
 Executive Summary
 
 

 

This estimation of national and subgroup totals and proportions is achieved by applying 

sample weights to each of the cases in the study. The weight applied to each elder abuse report can be 

thought of as indicating the number of cases nationally that are represented by the individual case in the 

study. By aggregating these sample weights for the relevant study cases, national and subgroup estimates 

are obtained, both of total numbers of elders, and their characteristics. 

This methodology is routinely applied in national samples to measure social and economic 

issues. The Current Population Survey, which (among other things) produces the official U.S. monthly 

national estimates of unemployment and employment, is one well-known example. Another is the Health 

Interview Survey, which produces periodic national estimates for a wide range of health measures. 

There were a number of steps involved in the process of developing weights for the 

NEAIS data. These are described in Chapter 3 of the full report, and in Appendix L.4 

Interpreting Results in the Presence of Sampling Variability 

A common technique used to present and interpret statistical data that are subject to 

sampling variability is through the use of confidence bands. A frequently used convention is to determine 

a 95 percent confidence band for each estimate. The statistical interpretation of a 95 percent confidence 

band is that, if such a band were constructed from all possible samples that might have been selected, 95 

percent of such bands would contain the true answer. 

If the confidence band for an estimate is wide, relative to the size of the estimate itself, 

then this indicates that there is considerable uncertainty as to what the true value actually is. If, however, 

the band is narrow, then there can be confidence that the estimate is close to the true answer. Thus, for 

example, consider an estimate that a certain population characteristic is at the 10 percent level. If the 

confidence band for this estimate ranges from 1 percent to 19 percent, we can have confidence that the 

true level is something below 20 percent, but cannot draw any other inference with confidence. If an 

4 The most important steps are the determination of overall probabilities of selection, calculation of nonresponse adjustments, and development 

of replicate weights. Unlike the sentinel records, there are no further sampling or nonresponse adjustments for the APS data, since all APS 

agencies in the sampled counties participated. One straightforward calculation is the annualization of the data. The staggering of different-sized 

counties throughout 1996 minimized the potential for seasonal affect to bias the estimates. Accordingly, this estimate of elder abuse over these 

two-month periods was transformed to an estimate for the full 1996-study year by multiplying the factor by six. 

16
 Executive Summary
 
estimate of 10 percent is accompanied by a confidence band that ranges from 9 percent to 11 percent, then 

we can be confident that the true figure is little different from 10 percent. 

Because the NEAIS sampled a relatively small number of counties, agencies, and 

sentinels, for many of the rarer characteristics described in this report the confidence bands are relatively 

wide (like in the first example given in the previous paragraph). When this has occurred, the estimates 

presented in the report are duly noted as having this characteristic. 

Conclusions 

The results of the National Elder Abuse Incidence Study (NEAIS) strongly confirm the 

validity of the “iceberg” theory of elder abuse that has been accepted in the aging research community for 

20 years or more. The contribution the NEAIS has made to our understanding of the extent of elder abuse 

and neglect is graphically depicted by the large new middle area in Figure ES-1 below. 

Reported abuse and neglect: 70,942 

estimated new incidents substantiated 

by APS. 

Unreported abuse and neglect: 378,982 

estimated new incidents reported by 

sentinels but not reported to APS. 

Unidentified and unreported new 

incidents. 

Figure ES-1.Iceberg theory showing NEAIS identified unreported abuse and neglect, excluding selfneglect 

17
 Executive Summary
 
 

The NEAIS findings lead to the following conclusions: 

� Domestic elder abuse and neglect is a significant problem. NEAIS research shows that about 

450,000 unduplicated elders experienced abuse and neglect in domestic settings in 1996. 

More than five times as many of these incidents of abuse and neglect were unreported than 

were reported to and substantiated by APS agencies.5 

� When elders who experienced only self-neglect are included with those that were abused and 

neglected, the number increases to 551,000 unduplicated elder persons in 1996. Almost four 

times as many of these incidents were unreported than were reported to and substantiated by 

APS agencies.6 

� The NEAIS has measured a large and previously unidentified and unreported portion of elder 

abuse and neglect, and also has learned much about the characteristics of the victims and 

perpetrators of abuse and neglect. 

� At the same time, it was not possible to identify and report on all previously hidden domestic 

elder abuse and neglect. Clearly, the NEAIS has not measured abuse, neglect, and selfneglect among those most isolated elders who do not leave their homes or who rarely come in 

contact with others in the community. 

� Several of the characteristics of abused and neglected elderly persons are particularly 

worrisome and challenge us to prevent and intervene in this tragedy: 

� Our oldest elders (80 and over) are abused and neglected at two to three times their 

proportion of the elderly population. 

� Female elders are abused at a higher rate than males. 

� Almost half of substantiated abused and neglected elderly were not physically able to 

care for themselves. 

� In almost nine out of ten incidents of domestic elder abuse and neglect, the 

perpetrator is a family member. Adult children are responsible for almost half of 

elder abuse and neglect. 

� Elderly self-neglect also is a problem, as evidenced by about 139,000 unduplicated reports 

(some of the self-neglecting elderly may also be counted as being abused and/or neglected). 

Most victims of self-neglect are unable to care for themselves and are confused. This is a 

difficult and troubling problem, which warrants further research and study. 

5

 Using precisely developed standard errors, the NEAIS estimates that as many as 688,948 or as few as 210,900 elder persons may have been 

abused and/or neglected in domestic settings in 1996. 

6 When self-neglecting elders are added, the estimate range is that as many as 787,027 or as few as 314,995 elder persons may have been abused, 

neglected, and/or self-neglecting in domestic settings in 1996. 

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 Executive Summary
 
� Despite the study’s identification of over five times as many unreported incidents of elder 

abuse and neglect as incidents that were reported to and substantiated by APS agencies, some 

professionals and researchers in the aging field may have expected this multiplier to be larger 

than NEAIS found. The NEAIS estimate may be lower than those expectations because: 

� Elder abuse and neglect are not as hidden and under-reported to APS agencies as they 

were at the time of earlier studies. Between 1986 and 1996, for example, official 

reports of abuse and neglect made to APS agencies throughout the country increased 

by 150 percent, while the total number of elderly persons aged 60 and over increased 

by only 10 percent. A much larger proportion of new incidents of domestic elder 

abuse and neglect was reported to official APS agencies in 1996 than was reported 10 

years ago. 

� Still more of the unidentified and unreported area of the iceberg remains to be 

revealed, especially instances of abuse and neglect among seriously isolated elderly 

persons and those with little contact with community organizations. 

Limitations of NEAIS 

The NEAIS study design had some limitations that prevented it from making a definitive 

estimate of all incidents of elder abuse and neglect, including: 

•	 The sentinel approach tends to cause a certain amount of “undercount” in the detection of 

domestic elder abuse because there are no community institutions in which most elders 

regularly assemble and from which sentinels can be chosen and elders observed (unlike 

schools in child abuse research). 

•	 Sentinels cannot observe and report abuse and neglect of elders who are isolated and/or have 

no or very limited contact with any community organizations. 

•	 Resource constraints for conducting the NEAIS limited the number of counties and sentinels 

sampled and the length of the reporting period. Consequently, the relatively small number of 

sentinel reports resulted in incidence estimates with wide confidence bands. Increasing the 

sample size and reporting period in future such studies would further improve the precision of 

incidence estimates through the calculation of narrower confidence bands. 

Implications of Findings and Future Research Questions and Issues 

The findings of the NEAIS suggest a number of important issues for policy development, 

practice, and training in addressing the problems of elder abuse, neglect, and self-neglect. Because states 

and localities historically have had responsibility for elder abuse reporting, investigation, and services, 

most of the implications are for state and local governments. These issues are discussed in the full report. 

Finally, the report raises a number of research questions and issues for researchers and service providers, 

including suggesting areas for future research of the incidence and nature of elder abuse and neglect. 

19
 Executive Summary
 
Conclusion 

The NEAIS has documented the existence of a previously unidentified and unreported 

stratum of elder abuse and neglect, thus confirming and advancing our understanding of the “iceberg” 

theory of elder abuse. NEAIS estimates that for every abused and/or neglected elder reported to and 

substantiated by APS, there are over five abused and/or neglected elders that are not reported. The study 

also documents similar patterns of underreporting of self-neglecting elders. NEAIS acknowledges that it 

did not measure all unreported abuse and neglect. Our collective challenge—as policy makers, service 

providers, advocates, researchers, and our society as a whole, is to utilize this information to better the 

lives of our elderly citizens. 

20
 Executive Summary
 
 

1. INTRODUCTION
 

Congress, under the Family Violence Prevention and Services Act of 1992 (P.L. 102-295), 

required that a study of the national incidence of abuse, neglect, and exploitation of elderly persons be 

conducted. The Administration for Children and Families (ACF) has responsibility for administering the 

provisions of this legislation. The ACF combined resources and expertise with the Administration on 

Aging (AoA) and jointly funded the study as a research activity of the AoA-supported National Center on 

Elder Abuse (NCEA). 

The American Public Welfare Association,1

 the lead organization for the NCEA, and its 

subcontractor, Westat, Inc., a survey research company located in Rockville, Maryland, conducted the 

study between October 1994 and December 1997. Because the legislative mandate primarily was 

concerned with the prevention of violence in domestic settings, the study focused only on the maltreatment 

of non-institutionalized elderly. Elders living in hospitals, nursing homes, assisted living facilities, or other 

institutional or group facilities were not included in the report. 

The National Elder Abuse Incidence Study (NEAIS) utilized a sentinel research design. This 

methodology for collecting data from nationally representative samples was new to the field of elder abuse, 

but this methodology already had been used for federally supported national incidence studies of child 

abuse and neglect, for example the Third National Incidence Study of Child Abuse and Neglect (NIS-3) by 

Westat for the National Center on Child Abuse and Neglect in ACF. Within ACF and other professional 

communities, the sentinel data collection approach has been accepted as a less costly alternative to a 

general population survey. 

Accordingly, using a sentinel methodology, NEAIS collected data from two different sources 

in a nationally representative probability sample of 20 counties: (1) local Adult Protective Services (APS) 

agencies or the Area Agencies on Aging (AAA); and (2) approximately 1,100 trained "sentinels" from 

public and private agencies that had frequent contact with elderly community residents. The function of the 

sentinels was to be on the lookout for incidents of elder abuse and to document each event that met the 

study's definitions. Many sentinels were mandatory or voluntary reporters of elder abuse as defined by 

Association members voted to change the name of the American Public Welfare Association to the American Public Human Services Association in 

July 1998, and it is hereafter referred to as APHSA. 

1-1
 

1
state laws and were employed by a variety of organizations (e.g., elder care providers, hospitals and clinics, 

law enforcement agencies, and financial institutions). 

Most previous attempts to generate national data on domestic elder abuse in the United States 

relied on statistics of suspected elder abuse compiled by states. Over the past 20 years, states have become 

increasingly concerned with the problem of elder abuse, both domestic and institutional, and have enacted 

laws to prevent and treat the problem. As a result, all states now have statutes addressing elder abuse. 

Most elder abuse laws require that certain professionals report all suspected incidents of elder maltreatment 

to officially designated report-receiving agencies. Eight states (Colorado, Illinois, New Jersey, New York, 

North Dakota, Pennsylvania, South Dakota, and Wisconsin) administer domestic elder abuse laws, but 

make elder abuse reporting voluntary. In some states, like Massachusetts, the elder for whom a report of 

suspected abuse has been made may refuse an investigation. Both the states with laws on mandatory 

reporting and those where reporting is voluntary regularly gather statistics on reports of elder abuse, 

although the comprehensiveness of elder abuse information systems varies considerably from state to state. 

The National Center on Elder Abuse, in a 1995 report (Tatara, 1995), documented 71 laws in 

the 50 states, the District of Columbia, Puerto Rico, Guam, and the Virgin Islands that address abuse, 

neglect, and exploitation of elders. Across these 71 state laws, the five most common information elements 

are: (1) type of person covered by the law; (2) definitions of elder abuse, (3) reporter immunity, (4) age of 

persons covered by the law, and (5) agency designated to receive reports. Other elements include: the 

timing/method of reporting, mandatory reporting requirements, mandatory reporters, involvement of law 

enforcement, and confidentiality of client information. 

Following the intake of a report of alleged abuse in an agency designated to receive these 

reports, such as APS, the case is assigned to a protective service worker for investigation. The length of 

time that elapses prior to the investigation varies both by state and by the nature of the abuse. Thirty states 

currently have laws that include provisions concerning the timing of investigating elder abuse reports. Five 

states (Alabama, District of Columbia, Florida, Idaho, and New Hampshire) require that reports involving 

a life-threatening or emergency situation be investigated immediately; five states (Guam, Kansas, 

Maryland, Minnesota, and Virgin Islands) specify that a report involving a life-threatening situation must 

be investigated within 24 hours; and 13 states (Alaska, Arkansas, California, Colorado, Kentucky, 

Louisiana, Maine, North Carolina, North Dakota, Oklahoma, Oregon, Tennessee, and Virginia) have laws 

requiring that all reports must be investigated "as soon as possible," but do not specify a particular amount 

of time. 

1-2
 
 

Once an investigation of an alleged elder abuse incident has begun, a case still may be 

"referred" to another agency for intervention or services. A case may be found substantiated, 

unsubstantiated, or in some states, "indicated but not confirmed." The requirements for case disposition 

vary by state. 

This study explicitly has been designed to measure the incidence of elder abuse and neglect 

rather than prevalence. The term incidence refers to new cases occurring during a specific period of time 

(Freeman and Sherwood, 1970). In contrast to incidence, prevalence refers to the total number of ongoing 

cases in a given population at a designated point in time. Prevalence is similar to a census and does not 

address when the abuse or neglect occurred. The NEAIS examines the incidence of newly filed reports of 

abuse and neglect during calendar year 1996. Ongoing cases which were not reported or identified during 

the study period (e.g., the abuse occurred prior to 1996) are not counted. 

In order to maximize the utility of the research, the study also collected and analyzed data 

about elder self-neglect in domestic settings, and these findings generally are reported separately from the 

findings for abuse and neglect. In the NEAIS, the phrase “elder maltreatment” refers to the seven types of 

abuse and neglect that are measured in the study, which are carefully defined later in this report. The 

incidence estimates calculated are for unduplicated elderly persons. In other words, individuals are counted 

only once, even if: (1) they were abused and neglected and/or self-neglecting, (2) more than one report 

were received about the same incident, or (3) different incidents were reported for the same elderly person 

during the study period 

The Organization of This Report 

This final report of the National Elder Abuse Incidence Study (NEAIS) contains estimates of 

the national incidence of abuse, neglect, and exploitation of older people in domestic settings and 

information about the characteristics of elder abuse perpetrators and victims, including self-neglecting 

elders. The report is organized into four additional chapters: 

Chapter Two provides background about prior efforts to measure elder abuse and neglect. 

Chapter Three details the inception of the National Elder Abuse Incidence Study and the 

reasons for conducting this important research. This chapter also provides an overview of the study design 

1-3
 
and discusses why a sentinel approach was used. Definitions of elder abuse, neglect, exploitation, and selfneglect are presented, as are the sampling plan for the study, instrument development, and recruitment and 

training procedures for APS and sentinel agencies. In addition, data collection processes and data handling 

are discussed, along with methods for weighting the data. 

Chapter Four provides the findings from the NEAIS, from the estimated national incidence of 

abuse and neglect of elderly people, to in-depth analyses of characteristics of the abused, neglected, and 

self-neglecting elderly, those who were perpetrators of this abuse and neglect, and those who reported this 

abuse or neglect. 

Chapter Five provides the summary, recommendations, and conclusions of this study. 

1-4
 
1-5
 
2. BACKGROUND
 

Studies designed to estimate the prevalence or incidence of the maltreatment of noninstitutionalized elders, or "elder abuse in domestic settings," have varied considerably in their research 

methodologies and sources of data. A review of these earlier studies reveals that one or more of the 

following five sources of data have been used to explore the extent and nature of elder abuse in domestic 

settings: (1) elderly people receiving services from an agency; (2) professionals and paraprofessionals 

working with elderly clients; (3) case records or reports of elderly clients prepared by professionals; (4) 

reports of alleged elder abuse received by Adult Protective Services (APS) or aging agencies; and (5) a 

probability sample of the elderly taken from the population in a specific geographic location. Study 

purposes and goals, age and abuse definitions, sample sizes, data-gathering methods, analytic tools, and 

results and their implications differ from one study to another. Some of these studies attempted to generate 

national estimates of the prevalence or incidence of domestic elder abuse, while others confined the 

discussion of results to the population from which data were drawn. The prevalence or incidence of 

domestic elder abuse estimated by these early studies ranged from one to nearly ten percent of the study 

sample or of the national elder population. 

Gioglio and Blakemore (1982) found that only one percent of the elderly respondents of a 

random sample of elders in New Jersey were victims of some form of elder abuse. After examining the 

records of elderly patients served by a Chronic Illness Center in Cleveland, Ohio, Lau and Kosberg (1979) 

reported that 9.6 percent of 404 patients showed symptoms of abuse. Further, Block and Sinnott (1979) 

investigated the "battered elder syndrome" in Maryland and found 4.1 percent of the elderly survey 

respondents were being abused. Other researchers have surveyed or interviewed social workers serving the 

elderly (Dolon and Blakely, 1989; Douglas, Hickey, and Noel, 1980; O'Malley, Segars, Perez, Mitchell, 

and Knuepfel, 1979; Sengstock and Liang, 1982) about the abuse of noninstitutionalized elderly. These 

researchers, however, did not translate their findings into national elder abuse prevalence rates. 

Based on a survey of state human service agencies and a review of secondary data, the House 

Select Committee on Aging (1981) released a statement that "some four percent of the Nation's elderly may 

be victims of some sort of abuse, ranging from moderate to severe." This estimate suggests that one out of 

every 25 older Americans, or about one million people in the early 1980s, were abused each year. 

In another study conducted by Pillemer and Finkelhor in 1986, one of the main objectives was 

to generate a national prevalence rate of domestic elder abuse. After conducting interviews with a random 

2-1
 
2.1 

sample of more than 2,000 elderly people in the Boston metropolitan area, these researchers (1988) 

reported that the prevalence of domestic elder abuse (excluding self-neglect and financial exploitation) was 

32 per every 1,000 elders (or 3.2 percent). Using this rate, the researchers calculated an estimated 

prevalence number of abused elders in the United States, which ranged between 701,000 and 1,093,560. 

Tatara (1989, 1990, 1993, Tatara and Blumerman, 1996, and Tatara and Kuzmeskus, 1997) 

disseminated national elder abuse data, primarily using state statistics for reports of alleged elder abuse. 

To help states achieve greater compatibility in definitions, reporting methods, and information management 

practices, Tatara published Suggested State Guidelines for Gathering and Reporting Domestic Elder 

Abuse Statistics for Compiling National Data (1990). Tatara began providing national data on domestic 

elder abuse about 10 years ago, but has recently analyzed national data on domestic elder abuse for 1995 

and 1996 (Tatara and Kuzmeskus, 1997). These data indicated that there were 293,000 reports of 

domestic elder abuse to state Adult Protective Services in the United States for 1996, a 150 percent 

increase from the 117,000 reports in 1986, the first year a national estimate of domestic elder abuse reports 

was calculated. 

Although these past studies have contributed to an increased understanding of the nature and 

extent of the maltreatment of non-institutionalized elders in this country, they were based on relatively 

small samples and did not provide national estimates of elder abuse incidence. The study described in this 

report provides, for the first time, national incidence estimates (i.e., new incidents occurring during 1996) 

of elder abuse that will serve as a baseline for future research in this important area. 

Overview of the Study Design 

The National Elder Abuse Incidence Study (NEAIS) gathered data on domestic elder abuse 

and neglect, using standardized definitions and data collection forms, in a nationally representative sample 

of 20 counties. The standardized abuse and neglect definitions used for the study were developed through 

the following steps: (1) an analysis of the current state definitions of domestic elder abuse; (2) the 

convening of roundtables of professionals working with elderly people to gather firsthand information 

about how domestic elder abuse is detected, reported, and investigated; and (3) the establishment of study 

definitions of elder abuse by a group of elder abuse experts. The definitions, along with data collection 

forms, were pilot tested in several local sites before being finalized. 

2-2
 
2.2 

In each sampled county, data were collected from two sources: (1) the local officially 

designated APS agency or the Area Agency on Aging; and (2) professionals and nonprofessionals, called 

"sentinels." Using random selection procedures, approximately 1,100 sentinels were chosen from 248 

agencies across the 20 sampled counties. The agencies chosen for the study were organizations that 

regularly work with the elderly (e.g., senior citizen centers and home health care providers), as well as 

others that serve everyone in the community (e.g., hospitals and clinics, law enforcement agencies, and 

banks). 

Using a specially made video and instructional guide, APS and sentinel reporters were trained 

to identify elder abuse according to study definitions and specific signs and symptoms and to record data on 

specially designed forms. Sentinels reported on abuse in each sampled county over a 2-month period on a 

staggered, 12-month schedule. APS agencies supplied information on all incidents reported to them over 

comparable time periods. This plan permitted the study to account for possible seasonal affects in the 

occurrence of elder abuse. Duplicate reports by sentinel agencies and between sentinel agencies and APS 

agencies were removed to avoid overcounting the true number of incidents. Finally, the unduplicated cases 

were weighted to arrive at national estimates. 

The Uniqueness of a Sentinel Approach 

The method of collecting data used for this study is known as a "sentinel approach." 

Developed by Westat almost 20 years ago, this Maryland-based survey research company conducted the 

nation's first child abuse incidence study. The sentinel approach was proposed as an alternative to more 

costly studies of general population surveys and has been used for all three national incidence studies of 

child abuse commissioned by the Federal government, with the most recent one completed in 1997. A 

sentinel approach is based upon the assumption that officially reported cases of abuse represent only the tip 

of an iceberg and that many more abuse incidents take place in the community. Whatever the reasons, 

many incidents are not reported to authorities. The supposition that reported cases of child abuse and elder 

abuse are only the tip of a much larger unidentified and unreported problem is well accepted by both child 

and elder abuse professionals. Figure 2-1 on the next page depicts the iceberg theory of elder abuse. 

2-3
 
Reported abuse 

Unidentified and 

unreported abuse 

Figure 2-1. Iceberg theory of elder abuse 

Using a sentinel approach, better information about unreported abuse can be obtained from 

individuals who are close to the victims by training them to be on the lookout for abuse incidents. With the 

strategic use of APS/aging professionals and well-trained sentinels from programs such as visiting nurses, 

home health care professionals, and hospital emergency room staff, this approach is capable of identifying 

many domestic elder abuse incidents that would not have been reported previously. 

2-4
 
3. STUDY DESIGN AND METHODS
 

Chapter Three presents the study design and methodology used in the National Elder Abuse 

Incidence Study (NEAIS). The chapter begins with the definitions of elder abuse, neglect, and exploitation. 

It then presents the sampling methodology for both Adult Protective Services (APS) and sentinel agencies, 

and agency recruitment and training procedures. This chapter then describes the data collection 

methodology, the unduplication of reports, and weighting of final results. Finally, a brief discussion of 

interpreting research results in the presence of sampling variability is provided to assist the reader in 

understanding the study findings, which follow in the next chapter. 

3.1 Definitions 

One of the problems in collecting data on elder maltreatment from states is a lack of 

comparability in the definitions of abuse, neglect, and exploitation. This lack of comparability stems 

largely from the fact that ours is a federal system of 50 semi-sovereign states. In addition to the variability 

among state laws, experts continue to disagree on definitions; for example, there has not been a universal 

acceptance of the federal definitions of elder abuse found in the Older Americans Act. A common set of 

definitions across jurisdictions is essential for a national study. For this reason, NEAIS developed a set of 

standardized definitions of elder mistreatment for the study. The use of these standardized definitions, 

along with thorough training of the people who collected data in the study sites, ensured greater 

comparability and reliability of results. 

Steps in Establishing Definitions 

The development of standardized elder abuse definitions involved several steps, including (1) 

an initial analysis of current state definitions of domestic elder abuse; (2) the convening of local 

roundtables of practicing professionals to gather firsthand information about how elder abuse is detected, 

reported, and investigated; (3) a critical review of preliminary definitions by a group of elder abuse experts; 

and, finally, (4) pilot testing the consensus definitions in both APS and sentinel agencies. 

3-1
 
Analysis of Current State Definitions. A table that documented the frequencies of the 

components of the definitions (see Appendix A) was prepared, following the analysis of existing state laws 

defining abuse, neglect, and exploitation. The components of the definitions were categorized by type of 

abuse and state. The specific types of abuse, and any subcategories, were identified. The most common 

components across the states were selected as potential elements of NEAIS definitions. 

Convening of Local Roundtables. Two roundtables of local professionals who deal with 

elder abuse, neglect, and exploitation were convened in February 1995 in San Francisco and in 

Washington, DC. The purpose of these roundtables was to obtain firsthand information from professionals 

working at the community level regarding how elder abuse is detected, reported, and investigated. The 

information obtained from these roundtables aided in the development of the standardized elder abuse 

definitions. (See Appendix B.) 

Consensus Meeting. A consensus meeting was held in Washington, DC, on May 1 and 2, 

1995. Participants included the members of the advisory committees of both the National Elder Abuse 

Incidence Study and the National Center on Elder Abuse, the APWA staff of the National Center on Elder 

Abuse (NCEA), the staff of NCEA's Consortium organizations, and Westat. Participants discussed the 

design of the study and provided an in-depth analysis of the draft definitions. Based on the discussion at 

this meeting, the definitions were revised and prepared for pre-testing. (See Appendix C.) 

Pilot-Testing. The definitions were pilot-tested in local Adult Protective Services (APS) and 

sentinel agencies and revised through iteration, based on the results of the tests. The pilot testing process is 

discussed in greater detail in a later section of this report. 

Definitions of Elder Abuse, Neglect, and Exploitation 

The following definitions of domestic elder abuse, neglect, and exploitation developed for the 

study pertain to elders living in non-institutionalized settings. 

Physical abuse is the use of physical force that may result in bodily injury, physical pain, or 

impairment. Physical abuse may include but is not limited to such acts of violence as striking (with or 

without an object), hitting, beating, pushing, shoving, shaking, slapping, kicking, pinching, and burning. 

3-2
 
The unwarranted administration of drugs and physical restraints, force-feeding, and physical punishment of 

any kind also are examples of physical abuse. 

Sexual abuse is nonconsensual sexual contact of any kind with an elderly person. Sexual 

contact with any person incapable of giving consent also is considered sexual abuse; it includes but is not 

limited to unwanted touching, all types of sexual assault or battery such as rape, sodomy, coerced nudity, 

and sexually explicit photographing. 

Emotional or psychological abuse is the infliction of anguish, emotional pain, or distress. 

Emotional or psychological abuse includes but is not limited to verbal assaults, insults, threats, 

intimidation, humiliation, and harassment. In addition, treating an older person like an infant; isolating an 

elderly person from family, friends, or regular activities; giving an older person a "silent treatment"; and 

enforced social isolation also are examples of emotional or psychological abuse. 

Neglect is the refusal or failure to fulfill any part of a person's obligations or duties to an 

elder. Neglect may also include a 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). 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. 

Abandonment is the desertion of an elderly person by an individual who has assumed 

responsibility for providing care or by a person with physical custody of an elder. 

Financial or material exploitation is the illegal or improper use of an elder's funds, property, 

or assets. Examples include but are not limited to cashing checks without authorization or permission; 

forging an older person's signature; misusing or stealing an older person's money or possessions; coercing 

or deceiving an older person into signing a document (e.g., contracts or a will); and the improper use of 

conservatorship, guardianship, or power of attorney. 

Self-neglect is characterized as the behaviors of an elderly person that threaten his/her own 

health or safety. Self-neglect generally manifests itself in an older person's refusal or failure to provide 

himself/herself with adequate food, water, clothing, shelter, safety, personal hygiene, and medication 

3-3
 
(when indicated). For the purpose of this study, the definition of self-neglect excludes a situation in which 

a mentally competent older person (who understands the consequences of his/her decisions) makes a 

conscious and voluntary decision to engage in acts that threaten his/her health or safety. 

The signs and symptoms of the seven kinds of abuse and neglect are summarized in Table 3-1. 

It should be noted that some signs and symptoms characterize several kinds of maltreatment. The most 

important of these are the following: 

� Frequent unexplained crying; and 

� Unexplained fear of or suspicion of particular person(s) in the home. 

Table 3-1. Signs and symptoms of abuse and neglect 

Physical Abuse 

� Bruises, black eyes, welts, lacerations, and rope marks 

� Bone fractures, broken bones, and skull fractures 

� Open wounds, cuts, punctures, untreated injuries, and injuries in various 

stages of healing 

� Stains, dislocations, and internal injuries/bleeding 

� Broken eyeglasses/frames, physical signs of being subjected to 

punishment, and signs of being restrained 

� Laboratory findings of medication overdose or under utilization of 

prescribed drugs 

� An elder's report of being hit, slapped, kicked, or mistreated 

� An elder's sudden change in behavior 

� A caregiver's refusal to allow visitors to see an elder alone 

3-4
 
Table 3-1. Signs and symptoms of abuse and neglect (continued) 

Sexual Abuse 

� Bruises around the breasts or genital area 

� Unexplained venereal disease or genital infections 

� Unexplained vaginal or anal bleeding 

� Torn, stained, or bloody underclothing 

� An elder's report of being sexually assaulted or raped 

Emotional/Psychological Abuse 

� Emotional upset or agitation 

� Extreme withdrawal and non-communication or non-responsiveness 

� An elder's report of being verbally or emotionally mistreated 

Neglect 

� Dehydration, malnutrition, untreated bedsores, and poor personal hygiene 

� Unattended or untreated health problems 

� Hazardous or unsafe living conditions (e.g., improper wiring, no heat or no 

running water) 

� Unsanitary or unclean living conditions (e.g., dirt, fleas, lice on person, 

soiled bedding, fecal/urine smell, inadequate clothing) 

� An elder's report of being neglected 

Abandonment 

� The desertion of an elder at a hospital, nursing facility, or other similar 

institution 

� The desertion of an elder at a shopping center or other public location 

� An elder's own report of being abandoned 

3-5
 
Table 3-1. Signs and symptoms of abuse and neglect (continued) 

Financial or Material Exploitation 

� Sudden changes in a bank account or banking practice, including an 

unexplained withdrawal of large sums of money by a person 

accompanying the elder 

� The inclusion of additional names on an elder's bank signature card 

� Unauthorized withdrawal of funds using an elder's ATM card 

� Abrupt changes in a will or in other financial documents 

� Unexplained disappearance of funds or valuable possessions 

� Provisions of substandard care or bills unpaid despite the availability of 

adequate financial resources 

� The provision of services that are not necessary 

� Discovery of an elder's signature forged for financial transactions or for 

the titles of the elder's possessions 

� Sudden appearance of previously uninvolved relatives claiming rights to an 

elder's affairs and possessions 

� Unexplained sudden transfer of assets to a family member or someone 

outside the family 

� An elder's report of financial exploitation 

Self-Neglect 

� Dehydration, malnutrition, untreated or improperly attended medical 

conditions, and poor personal hygiene 

� Hazardous or unsafe living conditions (e.g., improper wiring, no indoor 

plumbing, no heat or no running water) 

� Unsanitary or unclean living quarters (e.g., animal/insect infestation, no 

functioning toilet, fecal/urine smell) 

� Inappropriate and/or inadequate clothing, lack of necessary medical aids 

(e.g., eyeglasses, hearing aid, dentures) 

� Grossly inadequate housing or homelessness 

3-6
 
3.2 Sampling Counties, Agencies, and Sentinels 

Sampling at the County Level 

The design for NEAIS employed a stratified multistage sample of 20 nationally representative 

counties, selected with probability proportional to the number of elders living in these areas. These 

counties, called Primary Sampling Units (PSUs), were stratified by five variables: geographic region, 

metropolitan area, elder abuse reporting requirements (mandatory and non-mandatory), percentage of 

elders, and percentage of poor elders. The use of probability proportional to size (PPS) ensures an 

approximately self-weighting sample—that is, every abused elder in the country has approximately the 

same chance of being identified, regardless of location, when the measure of size is the number of elders in 

the PSU. 

This methodology produced the sample presented in Table 3-2 on page 3-9. Note that five 

counties were selected in each of four regions defined by the Office of Business Economics (OBE). These 

four regions have approximately equal populations. Five counties were from non-metropolitan areas, and 

five were from non-mandatory reporting states (i.e., where there is no state law requiring professionals to 

report suspected elder abuse). Note also that the numbers and percentages of elders are shown, as well as 

the percentage of the total county population that is made up of persons 60 years of age and older. The 

description of sampling methodology, presented in Appendix D, provides additional details on the 

distribution of counties in each of these strata. 

Figure 3-1 on the next page shows the states participating in the NEAIS separated into the 

four OBE regions: Northeast (Region 1); Southeast (Region 2); Central (Region 3), and West (Region 4). 

Sampling Sentinel Agencies within Counties 

The sentinel agencies were divided into four major categories: financial institutions (banks); 

law enforcement agencies (sheriff's departments and municipal police departments); hospitals (including 

public health departments); and elder care providers (ECPs), (e.g., adult day care centers, senior centers, 

home health care agencies). The sources for identifying sentinel agencies included the following: 

3-7
 
� Law enforcement—National Directory of Law Enforcement Administrators; 

� Hospitals—American Hospital Association Guide; 

� Public Health Departments—National Directory of Local Health Departments; 

� Banks—Dun & Bradstreet; and 

� Elder care providers—National Directory for Eldercare Information and Referral and 

local Area Agency on Aging (AAA) Directories of Elder Care Providers. 

Figure 3-1. States by OBE region, with participating NEAIS states in gray 

IV	 III
 I 

II 

3-8
 
Table 3-2. Sampled counties for the National Elder Abuse Incidence Study 

Number of elders % of 

OBE Metro Mandatory (% of population poorer PSU 

Region County State status reporting of the county1

) elders2 probability 

1 Delaware County PA metro no 113,225(20.67%) 6.99% 0.05418 

1 Fayette County PA metro no 34776(23.93%) 14.26% 0.01664 

1 Bristol County MA metro yes 96,576(19.07%) 10.40% 0.04621 

1 Mercer County NJ metro no 57,195(17.55%) 6.96% 0.02737 

1 York County ME nonmetro yes 27,911(16.96%) 9.28% 0.01336 

2 Pulaski County AR metro yes 54,111(15.48%) 14.10% 0.02607 

2 Pinellas County FL metro yes 271,330(31.86%) 7.70% 0.13071 

2 Cleveland County NC nonmetro yes 15,351(18.12%) 16.38% 0.00740 

2 Madison County NC metro yes 3,644(21.49%) 32.52% 0.00176 

2 Giles County TN nonmetro yes 5,311(20.63%) 21.79% 0.00256 

3 Dupage County IL metro no 95,655(12.24%) 3.67% 0.04624 

3 St. Clair County IL metro no 44,998(17.12%) 11.21% 0.02175 

3 Platte County MO metro yes 6,585(11.38%) 6.50% 0.00318 

3 Bay County MI metro yes 20,125(18.01%) 9.74% 0.00973 

3 Presque Isle County MI nonmetro yes 3,680(26.78%) 16.49% 0.00178 

4 San Diego County CA metro yes 360,842(14.45%) 6.00% 0.17265 

4 Maricopa County AZ metro yes 347,277(16.37%) 8.50% 0.16616 

4 Grayson County TX metro yes 20,088(21.14%) 15.47% 0.00961 

4 Multnomah County OR metro yes 101,659(17.41%) 10.08% 0.04864 

4 Rusk County TX nonmetro yes 9,575(21.89%) 19.57% 0.00458 

The regional average percentage of elders is 18.2 percent in Northeast, 18.3 percent in Southeast, 20.2 percent in the Central United States, and 

17.7 percent in the West. 

3-9 

1 
2 Below the poverty line in 1989 as defined by the U.S. Bureau of the Census (1990 Census Population Data). 

A sample of sentinel agencies was drawn from the 20 counties. In two rural counties, Rusk 

and Presque Isle, there were fewer than 12 eligible agencies (other than banks). Otherwise, on average, 12 

to 13 agencies per county were selected. Two banks per county were selected to ensure that possible 

incidents of financial exploitation of elders would be identified. The remaining agencies were distributed 

among the other three categories proportional to the number of agencies available in each county. 

Proportional allocation methodology was based on a simple logic that different categories of agencies 

should be appropriately represented in the pool of agencies sampled. 

Whenever possible, agencies were selected using a stratified probability proportional to the 

size of the agency. When a reasonable measure of size could not be ascertained, an equal probability 

sample of agencies was selected. A measure of size was available for most of the law enforcement 

agencies, hospitals, and banks, but not for the aging service providers. With slight modification for some 

sentinel agencies recruited late in the data collection period, the allocation of agencies in each county 

followed the following pattern: 

� Two banks; 

� At least one law enforcement agency; 

� No more than two municipal police departments; 

� No more than three law enforcement agencies (i.e., municipal police and sheriff's 

departments); 

� At least three hospitals; 

� Public health departments with certainty in small counties, if available; and 

� Sheriff's departments with certainty in small counties. 

Small counties, with fewer than 10,000 elders, included Madison, Giles, Presque Isle, and 

Rusk. These counties had too few agencies of one or more types required for the study. Rusk County did 

not have a public health department. Although the study design called for at least three hospitals per 

county, Bay County had only two hospitals; there was one each in Madison, Giles, Presque Isle, and Platt. 

There were no hospitals in Rusk County, and no banks in Presque Isle. 

3-10
 
Table 3-3 contains the available number of agencies by type, along with the number selected. 

Using PPS sampling by strata, an average of 12.4 sentinel agencies were selected in each county. Agencies 

chosen to replace agencies that had refused to participate were selected with the same probability as the 

sampled agencies. A description of sampling procedures for each type of agency and its potential 

replacements can be found in Appendix D. 

Table 3-3. Sentinel agency allocation by agency type 

Law Available 

Available enforcement hospitals/p Hospitals/ Available Total 

Banks law agencies ublic (PH) elder care ECPs ParticAvailable Partic- enforcement Partic- health Partic- providers Partic- ipating 

County Banks ipating agencies ipating (PH) ipating (ECPs) ipating agencies 

Maricopa 25 2 19 1 27 3 99 7 13
 

Rusk 7 2 4 3 0 0 3 3 8
 

Bay 30 2 6 3 2 2 5 5 12
 

Pinellas 23 2 23 2 25 3 105 6 13
 

Bristol 36 2 20 2 25 3 45 6 13
 

San Diego 34 2 20 2 20 3 90 7 13
 

Madison 6 2 2 2 1 1 18 8 13
 

St. Clair 24 2 20 2 24 4 59 6 13
 

Mercer 18 2 11 1 14 3 88 7 13
 

Giles 4 2 2 2 2 2 18 7 13
 

Fayette 12 2 13 3 3 3 25 5 13
 

Grayson 8 2 7 1 5 3 70 7 13
 

Multnomah 37 2 5 1 12 3 58 7 13
 

York 15 2 14 3 3 3 19 5 13
 

Presque Isle 0 0 3 3 1 1 4 4 8
 

Delaware 36 2 37 2 18 3 51 6 13
 

Dupage 29 2 31 2 9 3 116 6 13
 

Cleveland 2 2 4 1 4 3 18 6 12
 

Platte 6 2 6 3 1 1 19 7 13
 

3-11
 
Pulaski 28 2 5 1 15 3 63 7 13
 

Total 380 38 251 39 182 49 973 122 248
 

Sampling Sentinels within Agencies 

In the absence of knowledge of the propensity to observe elder abuse by different types of sentinels within a 

county, a self-weighting sample of 50 sentinels per county was proposed. This yielded a targeted total of 

1,000 sentinels. One disadvantage of this self-weighting design was the possibility of overburdening some 

agencies, that is, attempting to recruit sentinels at a very high rate in counties with a small number of 

eligible agencies. One elder care provider, for example, had 78 eligible sentinels and, under the selfweighting design, almost all of these sentinels should have been sampled. Only 11 were recruited at that 

atypical agency, however, in order to distribute the respondent burden evenly. The following guidelines 

were used: 

� Recruit at least one sentinel per agency; 

� Recruit no more than eight sentinels per agency (except in unusually large agencies); 

� On average, recruit four sentinels per agency; and 

� Recruit about 250 sentinels per agency type (across all 20 counties). 

If, during sentinel recruitment, it was learned that some potential types of sentinels were more 

likely to encounter abuse than others (e.g., the Elder Abuse task force in a police department), the selfweighting design was not used. Such special groups of sentinels were selected either with certainty or at a 

higher rate. During data collection it was learned that banks had fewer contacts with elders than ECPs; 

rates of sentinel recruitment were adjusted accordingly. 

Evaluation of the Sample of Counties and the Estimates 

Twenty counties (in 15 states) were selected to represent similar places across the continental 

United States, according to criteria discussed above and based on data from the 1990 Census. Altogether, 

there are more than 3,000 counties in the United States and, on average, more than 60 per state. The 

study's national annualized estimates are based on data obtained from a small fraction of these counties 

3-12
 
and, in addition, are derived from only 2 months of data. It is, therefore, important to examine the 

accuracy of the estimates using outside sources, to the extent possible. 

The National Center on Elder Abuse, in the spring of 1997, conducted A Survey of State APS 

and Aging Agencies on Domestic Elder Abuse [Data] for FY 95 and FY 96. A survey instrument, 

designed to collect aggregate statistics for domestic elder abuse, was sent to state APS agencies and State 

Units on Aging. Figures received from states in this survey represent counts of domestic elder abuse 

reports to state report-receiving agencies. A report may involve more than one elderly person and, 

similarly, one person may be reported more than once as an alleged victim of abuse. 

Data of similar character were collected from each of the county APS agencies in NEAIS for 

a 2-month period. These data were compiled to be comparable to the NCEA survey of domestic elder 

abuse reports, leaving duplicate and unsubstantiated cases in the totals. Then, using estimation methods 

described later, data were weighted to represent national totals and annualized. Table 3-4 below compares 

these annualized national estimates of APS data from NEAIS with totals obtained from the 48 contiguous 

states, by region. In each of the four regions, the proportion of cases in the data obtained from states by 

NCEA is very close to the national estimates. It was estimated, for example, that 16 percent of the 

weighted incidents reported by APS to the study came from Region 1, the Northeast; 17.5 percent of the 

reports from the states to NCEA were contributed by states in Region 1. Across the other three regions, 

there are differences of only a few percentage points between the NEAIS estimates and the NCEA actual 

totals. Furthermore, the total number of reports obtained directly from the states is fewer than 4,000 cases, 

(less than 1.5 percent) greater than the estimated total. The statistical procedures used to produce the 

national estimate appear to be extremely accurate. 

Table 3-4. NEAIS annualized national estimates from APS data in 20 

counties by region compared to NCEA's Survey of Domestic 

Elder Abuse Reports (duplicated totals) 

NCEA survey NEAIS 

State-by-state National estimates 

Region totals 1996 1996 

1 50,746 (17.5%) 46,403 (16%) 

2 74,881 (25.6%) 64,156 (22%) 

3-13
 
3.3 Instrument Development 

Since APS case workers and sentinel agency staff, rather than professional interviewers, 

would be completing data forms, their design had to be simple, requiring as few references as possible to 

other documents. Several versions of instruments were pretested with local APS and service agency staff 

to fine tune them and simplify procedures as much as possible. 

The APS and sentinel instruments were identical with two exceptions: the APS instrument 

included sections for reporting the sources of the report to the agency and for the disposition of the case. 

These items were not applicable to the sentinel instrument. Appendix E contains the data forms for APS 

and sentinel agencies. Insert pages ("Additional Parts A") were created for circumstances in which more 

than one elder in the household was abused. An additional Part A is also included in Appendix E. The 

final version of each instrument was a single 11" x 17" page printed back to back and folded in the middle. 

Pretesting Data Collection Instruments 

Pretests were conducted at six sentinel agencies and in two APS sites during the months of 

May, June, July, and August 1995. Participants were briefed in person on the purpose of the study and 

then asked to review each item on the form to see if the wording was clear and if the requested information 

was available in the records at the pretest location. Pretest participants were encouraged to critique the 

format and question order as well. Participants were given one or more forms and asked to complete them 

and return them to Westat by mail or fax. Eight APS forms and ten sentinel forms were received. Table 

3-5 below summarizes the pretest dates and number of forms received from each agency. 

Both APS and sentinel pretest offered many constructive comments agencies. During the 21⁄2 

months of pre-testing, the instruments were revised four times. Where appropriate, pre-testers' suggestions 

were incorporated into the final instruments. 

3-14
 

3 47,368 (16.3%) 56,868 (20%) 

4 117,318 (40.4%) 119,016 (42%) 

Total 290,314 (100%) 286,443 (100%) 
3.4 

Table 3-5. APS and sentinel agency pretest dates and number of forms received 

Agency Date completed Number of forms received 

Adult Protective Services 

Montgomery County 6/8/95 3 

Fairfax County 6/27/95 5 

Sentinel agencies 

The Support Group 5/23/95 4 

Potomac Home Care 7/13/95 1 

Fastran Transportation 5/31/95 1 

Crestar Bank 7/31/95 1 

Meals on Wheels 7/21/95 1 

In-home Hospice Care 8/25/95 2 

Total 18 

Institutional Review Board (IRB) 

The NEAIS study design and data collection forms and procedures were reviewed by the IRB 

at Westat on June 13, 1995, and twice annually after that. The project qualified for an exemption from the 

requirement to obtain informed consent because no identifiable information about victims of abuse, alleged 

maltreaters, or reporters of the abuse were recorded on any of the data collection forms. Because of the 

confidential nature of the information, however, the IRB cautioned that the data be safeguarded from any 

possibility of identifying the subjects of the reports or the reporters, and recommended several 

modifications to the forms and data collection procedures. (See Appendix F for IRB approval letter.) The 

final data set must be prepared in a format that eliminates the possibility of identifying counties, agencies, 

sentinels, or alleged victims. 

APS Agency and Sentinel Agency Recruitment 

Agency recruitment followed two different tracks: recruitment of APS agencies was the 

responsibility of APHSA; recruitment of sentinel agencies was the responsibility of Westat. Recruitment 

procedures for each type of agency are described below. 

3-15
 
APS Recruitment 

Adult Protective Services are provided by various agencies across the United States. The 

designation of the agency responsible for handling protective services is made at the state level, and the 

designated agency varies by state. In 29 states, the APS agency is located in the social services agency in 

the state. In 19 states, the APS program is located in the state unit on aging, but within the social service 

agency. In 6 states, the APS program is located in the state unit on aging and outside the social service 

agency. While the staff of most APS agencies receive and conduct investigations directly, in some states the 

APS agencies contract with local non-profit agencies to conduct elder abuse investigations and related 

activities (e.g., California and Illinois). These organizational variations mean that the NEAIS recruitment 

procedures involved different agencies in each state. (See Appendix G for the location of APS agencies by 

state.) Regardless of their locations in the state structure, many APS agencies limit their protective 

services to vulnerable elders (e.g., dependent, impaired, or incapacitated persons). 

The recruitment of APS agencies involved several steps. In mid-April of 1995, a letter of 

introduction and an agreement form was sent to APS/aging agency directors in each sampled county. The 

agreement form, once signed by the agency director, committed an agency to participate in the study and 

designated a "local contact person." Between April and August of 1995, agreements to participate were 

received from 19 of the 20 sampled counties. During August of 1995, a letter and questionnaire were sent 

to designated local contact persons. The questionnaires were used to collect baseline data for each county, 

as well as information helpful in the design of the data collection forms and training materials. By 

December 1995, after determining that the remaining agency, Westchester County, NY, would not 

participate in the study, Delaware County, PA, was selected as a replacement. Delaware County was 

selected randomly from counties with characteristics as similar as possible to Westchester County. 

Delaware County agreed to participate in January 1996. 

Sentinel Agency Recruitment 

Local service agency directories typically did not include names of directors or agency 

employees. When such names were provided, they were not necessarily current or might not be the 

appropriate contact person. Accordingly, Westat staff contacted each sentinel agency and asked for the 

name and title of the person who would be able to decide about the agency's participation in a national 

3-16
 
study on elder abuse. Westat then confirmed the decision-maker's telephone number, fax number, and 

street address. 

The initial contact letters were sent sufficiently early to allow recruitment to be completed 

before the start of data collection. Two different contact procedures were utilized, depending on the type of 

agency. For smaller agencies, contact letters were sent 4 to 6 weeks before the beginning of data collection. 

For larger agencies or agencies likely to have several levels of bureaucracy, 6 to 8 weeks of lead time was 

allowed; for example, hospitals often referred our recruiters to three or four people before the decision 

maker could be identified. Even then, many required the approval of legal departments, research 

committees, or approval through their own IRB. 

Selection of Sentinels within Agencies 

If possible, sentinels were sampled during the recruitment telephone conversation with the 

person designated by the sentinel agency to be the point of contact with NEAIS. To be eligible for the 

sample frame of sentinels from the agency, persons had to have frequent contact with the elderly and had to 

be able to identify abuse if they encountered it. Each attempted call to an agency and the outcome of the 

call were recorded on a telephone log. When the person listed as the addressee or another person who could 

make a decision concerning the agency's participation was successfully contacted, a recruitment script was 

used to ask a series of questions on the structure and size of the agency. Because the kinds of agencies 

participating in the study had very different organizational features, different scripts were developed for 

different kinds of organizations such as law enforcement agencies, in-home service providers, out-of-home 

providers, senior centers, and banks. 

A Microsoft Excel program was used to randomly pick every nth sentinel from a roster of 

sentinel candidates provided by the agency. Part-time as well as full-time agency staff were eligible for 

consideration. Professional staff were preferred, although volunteers were selected occasionally when 

professional staff were not available. The number of sentinels selected per agency was typically four to 

six, according to sampling guidance received from project statisticians. In some instances, an agency's 

participation was contingent on taking all eligible staff (e.g., an entire emergency room staff at a hospital). 

In such cases, the project accepted the agency's designated participants and noted the special circumstances 

so that proper weighting could be attached to these unusual agencies. Table 3-6 shows the numbers and 

percentages of sentinels who were sampled and who participated, after accounting for refusals and sentinels 

3-17
 
who left the agency. Among the 1,158 sentinels who were asked to participate in the study, only 4 refused 

to do so. 

APS and Sentinel Agency Followup Procedures 

Data collection took place over a 12-month period, according to the schedule presented in 

Figure 3-2, with either one or two counties starting data collection each month for 12 months. Sentinel 

data collection took place over an 8-week period, while for APS agencies in the same counties, data 

collection extended 2 weeks beyond the second month so that any instances of abuse or neglect identified by 

sentinels at the end of the data collection period could be included in the APS database, if reported to the 

local APS agency. 

Table 3-6. Sentinel participation status, by agency type 

Sentinel 

Status Sheriffs 

Municipal 

police 

Agency type 

Public health 

departments Hospitals Banks 

Service 

providers Total 

Total selected 51 230 18 192 72 602 1165 

4.38% 19.74% 1.55% 16.48% 6.18% 51.67% 100.00% 

Left agency1 0 

0.00 

2 

0.17% 

0 

0.00 

1 

0.09% 

0 

0.00 

0 

0.00 

3 

0.26% 

Refused 0 

0.00 

2 

0.17% 

0 

0.00 

1 

0.09% 

0 

0.00 

1 

0.09% 

4 

0.34% 

Active participant 51 

4.38% 

226 

19.40% 

18 

1.55% 

190 

16.31% 

72 

6.18% 

601 

51.59% 

1158 

99.40% 

Participation rate 100% 99% 100% 99% 100% 99.8% 

1

 Excluded from participation rate 

3-18
 
2/13/98 

1995 1996 1997 

O N D J F M A M J J A S O N D J F M 

Maricopa and Rusk 

Bay and Pinellas 

Bristol 

Madison and San Diego 

St. Clair and Mercer 

Giles 

Grayson and Fayette 

Multnomah and York 

Dupage 

Presque Isle and Delaware 

Cleveland and Platte 

Pulaski 

1/2 3/14 

2/1 4/12 

3/1 5/14 

4/1 6/14 

5/1 7/15 

6/3 8/14 

7/1 9/16 

8/1 10/14 

9/2 11/14 

10/1 12/13 

11/1 1/15 

12/2 2/14 

Figure 3-2. Start and stop dates for each participating county 

Because of the substantial time lag between recruitment and data collection in many counties, 

it was important to remind agencies not currently involved in the study of their commitment to participate. 

For APS agencies, this was done by periodically sending a reminder letter and an incentive, for example, 

complimentary copies of Elder Abuse: Questions and Answers An Information Guide for Professionals 

and Concerned Citizens, the NCEA Exchange, and Fact Sheets. Sentinel agency contacts were called 

periodically to remind them of the upcoming data collection schedule and to alert them to expect an express 

package containing training materials and data collection forms. 

Adult Protective Services and Sentinel Training 

An innovative approach was developed for training sentinels and APS agency personnel using 

specially designed materials and a video. Training included the following items: 

3-19
 
� An attractive 17-page participant guide book (see Appendix E) provided information on 

the study design, confidentiality, responsibilities of study participants, definitions of 

elder abuse, and procedures for returning completed data forms; 

� Two 35-minute videos were developed—one for APS staff and the other for sentinel 

agencies; and 

� An "800" telephone number was available for participants to call with any questions 

about data collection procedures or client eligibility. 

Except for small differences in items on reporting sources and disposition of reported cases, 

the APS and sentinel videos shared the same core material. Westat prepared the scripts, with revisions 

suggested by the American Public Welfare Association (APWA) and the Administration on Aging (AoA) 

Project Officer. Two professional readers recorded the revised script in a professional sound studio. Next, 

Westat's graphics department merged the sound track with artwork produced in-house, making master 

tapes that were then copied onto VHS videotapes for distribution to APS and sentinel agencies during 

recruitment. 

In addition to being more cost effective than in-person training, a video approach has several 

other advantages. A training video is a reference tool that can be used to refresh the memories of sentinels 

and agency contact persons. In addition, it is easier to maintain the anonymity of participating sentinels 

and sentinel agencies through video training. 

Several weeks before data collection in a particular county, a call or letter reminded the local 

contact person that data collection would begin the following month. Approximately 1 week later, the 

following training package and data collection materials were sent: 

� A letter reconfirming the agreement to participate in the study; 

� A letter from the Assistant Secretary for Aging, AoA, Fernando Torres-Gil 

� A packing slip; 

� Training videotapes (typically, one for each of four participants); 

� Sentinel and APS/aging agency guidebooks (one copy for each participant, employee, 

or sentinel participating in the study); 

� Video viewing instructions; 

� Data collection forms; 

3-20
 
� Additional Parts A; 

� Transmittal sheets; 

� Pre-addressed/pre-stamped mailers; 

� Additional instructions for APS employees; and 

� Label sheets. 

The day after the training materials were scheduled to be received, the local contact person 

was called to ensure that the package had arrived and to schedule a conference call after APS workers and 

sentinels had an opportunity to view the training video and read the guide. See Appendices H and I for the 

Adult Protective Services/aging agencies training materials. 

The discussion of the contents of the video typically took place 1 week before the beginning of 

data collection. Site visits were scheduled midway through the data collection period at the first data 

collection site and at several others where assistance was needed. 

Recruitment of Alternate Sentinel Agencies 

Recruiters, project staff trained to persuade agencies to participate in the study, sometimes 

discovered during attempts to contact administrators that agencies had gone out of business, merged with 

another agency, or did not serve elderly clients. In such instances, an alternate agency was selected from a 

list of randomly assigned substitutes. The substitute agency was contacted after a recruitment package had 

been forwarded, as described above. 

Sentinel Agency Refusals and Refusal Conversions 

Several strategies were employed for "refusal agencies." These included, depending on the 

reason for the refusal, (1) express mailing a package with a persuasive letter and with the training video; 

(2) faxing a copy of the data collection instrument; (3) reassigning the agency to another recruiter; and (4) 

assigning the agency to senior project staff. Attempts to recruit a single refusal agency might employ all 

four strategies. Unless the refusal came from the most senior person at an agency, recruiters tried to 

persuade the contact person to identify someone else more senior to whom the recruiter or senior staff could 

3-21
 
3.5 

speak. During weekly staff meetings, project staff discussed alternative recruitment strategies, and a plan 

of action was developed for each refusal. A replacement agency was selected only after all recruitment 

efforts had been exhausted. Bank participation rates were particularly low. Most banks declined to 

participate on the advice of corporate counsel or senior bank staff. Efforts to secure a letter of endorsement 

from the American Bankers Association were unsuccessful. It is noteworthy that only one completed form 

was returned from a bank sentinel among the 16 participating banks. Agency participation status by type 

of agency is shown in Table 3-7. 

Table 3-7. Participation status, by agency type 

Agency type 

Status 

Total 

selection 

Sheriffs 

13 

Municipal 

police 

41 

Public health 

departments 

13 

Hospitals 

58 

Banks 

59 

Service 

providers 

280 

Total 

464 

(405) 

Ineligible/ 

Merged 

1 

(7.6%) 

1 

(2.4%) 

8 

(61.5%) 

7 

(12.1%) 

6 

(10.2%) 

109 

(39%) 

132 

(126) 

Refused 1 3 0 10 37 35 86 

(49) 

Participating 

agencies 

11 

(91.6%) 

37 

(92.5%) 

5 

(100%) 

41 

(80.4%) 

16 

(30%) 

136 

(80%) 

246 

(230) 

Participation Rate: Seventy-four percent including banks; 82.4 percent without banks. Total numbers in parentheses exclude banks. Total 

percentages in parentheses exclude ineligible or merged agencies. 

Data Collection 

As described earlier, data collection was spread over 12 months, beginning in January 1996, 

following the pattern presented in Figure 3-2. APS and sentinel procedures are described below. 

3-22
 
APS Data Collection 

On the first scheduled day for data collection in each county, a telephone call was made to 

remind the local contact person in the APS agency and to answer last-minute questions. Approximately 

every 10 days, the contact person was called to determine how many reports had been received by the 

agency and how many forms had been completed. These telephone calls provided continuous monitoring of 

the progress of the agency and allowed study staff to estimate the number of expected data forms. Finally, 

they provided the study participants with another opportunity to ask questions. 

The local contact person was reminded when 1 week remained in the data collection period. 

On the last day, the local contact person was asked to send in all completed forms. Within a month after 

the end of data collection in each county, forms received from the APS/aging agency were reviewed, coded, 

and entered into the database. Similar procedures were followed with sentinel agencies, in addition to the 

procedures noted below. 

Sentinel Data Collection 

Sentinel data collection procedures were similar to APS agencies; however, sentinels were 

asked to send reports without the approval or review by the agency contact. This procedure ensured that 

the agency contact—the person with responsibility for disseminating the data collection materials and 

talking weekly to Westat's home office about sentinel absences or replacements—did not inhibit the sentinel 

from forwarding cases. Information about sentinel absences or replacements obtained during these periodic 

telephone calls was used in weighting the data. Sentinels were also asked to forward reports of suspected 

cases of elder abuse as soon as possible after observing the suspected abuse. Sentinels did not attempt to 

substantiate incidents of abuse. 

Site Visits to APS/Aging Agencies and Sentinel Agencies 

Site visits to APS agencies were conducted for several reasons. Maricopa and Rusk were the 

first sites to begin data collection, and APHSA wanted to monitor how the study was being implemented. 

Bristol and San Diego Counties were visited at the request of the APS agencies. Multnomah was visited 

because a large number of cases were expected there. Madison County, on the other hand, was a very 

3-23
 
small county and APHSA wanted to observe any differences from larger sites in the implementation of the 

study. 

Table 3-8 shows the location and dates of site visits to six counties that were made to 

APS/aging agencies. 

Table 3-8. APHSA site visits to APS agencies 

County/state Site visit dates 

Maricopa County, Arizona 02/05/96 thru 02/09/96 

Rusk County, Texas 02/05/96 thru 02/09/96 

Bristol County, Massachusetts 03/13/96 thru 3/15/96 

San Diego County, California 04/10/96 

Madison County, North Carolina 04/30/96 

Multnomah County, Oregon 08/16/96 

Table 3-9 shows the location and dates of site visits conducted by Westat to five counties. 

These visits included the first (Maricopa and Rusk) and last (Pulaski) participating counties. Multnomah 

was visited because a large number of forms were expected from Multonomah sentinels. Cleveland County 

was visited because it was a nonmetropolitan county with a large percentage of elderly residents. Project 

staff met with sentinels and agency contacts at nearly all participating agencies in the five counties. Site 

visits were conducted to determine if sentinel agencies were following the procedures presented in the 

training video and APS/sentinel guide, to answer any questions from sentinels and agency contacts, and to 

gauge the degree of interest in the study by the participating agencies. Project staff found great interest in 

the study and diligence in following study procedures. (See Appendix J for site visit information.) 

Table 3-9. Westat site visits to sentinel agencies 

County/state Site visit dates Number of agencies visited 

Maricopa County, Arizona 02/05/96 thru 02/09/96 12 

Rusk County, Texas 02/05/96 thru 02/09/96 8 

3-24
 
Multnomah County, Oregon 08/26/96 thru 08/28/96 11 

Cleveland County, North Carolina 11/18/96 thru 11/19/96 12 

Pulaski, Arkansas 01/06/97 thru 01/08/97 13 

Certificates of Appreciation 

After data collection was completed in each county, a certificate of appreciation was mailed to 

each sentinel and sentinel agency contact, and to APS/aging agency staff. The certificates were produced 

on high-quality bond paper, with a gold, embossed seal certifying that the recipient had participated in the 

NEAIS. An example of the certificate is included in Appendix K. 

Special Procedures in San Diego, California 

San Diego County sentinel agencies required special data collection procedures because of 

difficulty in getting sentinel agencies there to return completed forms. Westat employed an experienced 

interviewer, who visited each agency to assist sentinels in completing and collecting forms. Prior to the 

interviewer's visit, a letter was sent to each agency contact informing that person of the data collector's 

visit. Despite the diligence of the interviewers, this procedure resulted in only three completed forms. It 

was not necessary to use in-person data collection visits in the other 19 participating counties. 

3.6 Data Receipt 

Data collection forms from both APS and sentinel agencies were sent to Westat. Westat staff 

reviewed sentinel forms for completeness and called the sending sentinel directly if there were any 

questions. Similarly, APHSA staff reviewed APS data forms and called the APS agency contacts to 

discuss missing or unclear data. 

APS agencies followed specific procedures for transmitting completed data forms to the home 

office, as detailed in the training video. The local contact person at the APS/aging agency was responsible 

for the collection and transmission of completed APS data forms. Following a review of the forms, the 

contact person then completed a two-ply transmittal form, kept a copy for his/her records, and forwarded 

3-25
 
the completed forms and transmittal sheet in a prestamped, pre-addressed envelope. Procedures varied 

slightly between the larger and smaller agencies. In larger APS agencies, several staff members checked 

the completed forms before the contact person sent them to the home office. In the smaller agencies, the 

data forms were often photocopied before the originals were sent to the home office. 

Sentinels followed procedures similar to those for APS agencies. The principal difference was 

that the role of the sentinel agency contact was limited to providing information to sentinels, training them, 

and distributing study materials. To encourage candid, confidential reporting, we asked agency contacts 

not to review or edit the forms completed by the sentinels. Moreover, sentinels were instructed to send 

forms directly to the home office, further insulating them from the possibility of influence by the agency 

contact. Sentinels were asked to complete and mail the data form on the same day a case was identified to 

minimize the possibility that events surrounding the abuse might be forgotten or incorrectly recollected. 

Sentinels kept a copy of the transmittal sheet and sent the forms in a pre-addressed prepaid mailer. 

Keying 

Both APS and sentinel data forms were entered into a data receipt system according to ID 

number, form type (APS or sentinel), and date of receipt; they were then batched in groups of 20. After 

batching, forms were keyed directly into a data entry program created in Microsoft Access. The data were 

entered using PCs with screens that mirrored the data collection instrument. 

Coding Data Forms 

Both APS and sentinel data forms required respondents to provide a brief narrative describing 

the maltreatment events. After keying, this maltreatment information was evaluated according to the study 

definitions and eligibility criteria. 

Cases that did not meet the study definitions were excluded from the database. A case was 

excluded for the following reasons: 

� Victim resides in an institutional setting (e.g., nursing home, foster care); 

� Victim is under 60 years of age; 

3-26
 
3.7 

� Victim resides outside county; or 

� The incident was not abuse by definitions used in NEAIS. 

In some instances, additional categories of maltreatment, other than the one coded by the 

respondent, were indicated based on the description of the alleged incident. A second trained staff person 

reviewed any proposed change in code before a final change was made. If necessary, miscoded items were 

reclassified into the proper category. 

A review of the APS data forms resulted in recording the maltreatment codes in 180 cases. 

During coding, 41 APS data forms were removed from the database for not meeting any of the seven 

definitions of elder abuse described earlier in this report. Only five sentinel forms were removed because 

they did not meet criteria. 

Unduplication 

Sometimes more than one data form was received for the same alleged maltreated elder 

describing either the same or different abusive incidents. It was necessary to identify such duplicates and 

count each person only once for purposes of this study. This process is known as “unduplication.” 

Various types of duplicate reports were submitted to the study concerning the same alleged 

maltreated elder. The first type was APS-APS duplication, in which an APS agency submitted two or 

more data forms on the same person. The second was sentinel-sentinel duplication, in which two or more 

sentinel forms were received on the same alleged maltreated elder. The forms could have come from the 

same sentinel or from different sentinels and/or from different participating agencies (e.g., a police station 

and a hospital). The third type was APS-sentinel duplication, which occurred either because the sentinel 

forwarded the incident to APS and both agencies subsequently submitted a data form to the study, or 

because the same incident was reported independently to APS by another source. 

To accommodate all possibilities for duplicate reporting, the data collected on the forms were 

sorted across three different groups using Microsoft Access, comparing elder's first name, last initial, date 

of birth, and age: 

� Exclusively across all APS data forms; 

3-27
 
� Exclusively across all sentinel forms; and 

� Crossing APS and sentinel forms. 

Possible duplicate cases across all possible combinations were identified after comments and 

other key data associated with the duplicate reports had been reviewed. Ninety-three sets of reports were 

determined to be genuine duplicates. Extra or duplicate cases reported both to APS and sentinel agencies 

were removed from the sentinel data file, so that such duplicated instances of abuse and neglect were 

counted as reports to APS. The largest number of duplicates (57 of the 93) were this type. Duplicate 

sentinel reports were assigned to the sentinel agency that first sent in the form. These numbers are 

presented graphically in Figure 3-3. 

APS Total: 1498 APS/Sentinel Duplicates: 

57 (Sentinels removed) 

APS/APS Duplicates:
 

32 (removed)
 

Unduplicated 

Sentinel Cases: 

140 

Sentinel/Sentinel 

Duplicates: 4 (removed) 

Sentinel 

Total: 201 

Unduplicated APS 

Cases: 1466 

3-28
 
Figure 3-3. Duplicated and unduplicated APS and sentinel reports 

3-29
 
3.8 Participant Tracking 

During the 2-month data collection period, sentinel agencies were called each week to confirm 

that the sampled sentinels were present on the job and thus were able to observe elder abuse if they 

encountered it. The outcome of each call was recorded in a database using a specially designed program 

that summarized information for each week. The information included whether the sentinel was a part-time 

or full-time sentinel during the week, and whether the sentinel was present most of the time or part of the 

time during scheduled hours. Sentinel tracking data were used in weighting the data. 

APS agencies were not tracked, since data were not collected from individuals within the 

agency, and the APS agency was presumed to be open during normal business hours. Nevertheless, 

APWA staff made frequent calls to APS agency contacts to monitor the progress of cases that were still 

under review to determine whether or not they had been substantiated. 

3.9 Weighting the Responses 

The process of weighting involves the computation of case-specific sampling weights used to 

produce unbiased estimates of the population parameters of interest. The weights are needed in the 

statistical analysis to compensate for the variable probabilities of inclusion in the sample. Even for 

samples in which units are selected with equal probabilities, weighting may still be necessary to compensate 

for differential rates of nonresponse and deficiencies in the sampling frame. Weighting complex survey 

data, such as the data from NEAIS, generally involves many steps. The most important steps are the 

determination of overall probabilities of selection, calculation of base weights, calculation of nonresponse 

adjustments, and development of replicate weights. A detailed explanation of the following components is 

provided in Appendix L. 

PSU Base Weights 

The base weight of a sampled county is defined as the reciprocal of the probability of 

selecting that county. The base weights are unbiased in that the expected value of a weighted estimate, 

based on the sample data, is equal to the corresponding population value that would have been obtained if 

3-30
 
all the counties (rather than a sample) in the United States were surveyed. The base weights of the sampled 

counties ranged from 5.79 (San Diego County, California) to 569.66 (Madison County, North Carolina). 

Weighting of APS Data 

Unlike the sentinel records, there are no further sampling stages for the APS data. In addition, 

there is no nonresponse adjustment, since all APS agencies in the sampled counties participated in the 

study. Therefore, all the records received from the APS agencies were assigned their respective PSU base 

weight and multiplied by an annualization factor of six (described below), to give the full sample final 

weight. 

Annualization 

The NEAIS data collection period extended from January 2, 1996, to February 2, 1997. Data 

were collected over a period of 2 months in each of the sampled counties. The counties were distributed in 

such a way that there were four or five counties reporting in any particular month, except at the beginning 

and the end of this period. In addition, a start date was assigned such that in most months, two large 

counties and two small counties were reporting, except at the beginning and the end of the study. This 

approach minimized the potential for a seasonal affect to bias the estimate of the incidence of elder abuse. 

The estimate of elder abuse over these 2-month periods was transformed to an estimate for the study year 

by multiplying by a factor of six. 

Agency Weight (non-APS Agencies) 

The agency base weight (ABW) of each non-APS agency is, in most cases, the inverse of the 

probability of selection. As described in the agency sampling description in Section 3.2, the probability of 

selection, in most cases, was obtained from the WESSAMP output. Within each county the selection 

probability was proportional to a measure of size of the agency so that the ABW was inversely 

proportional to the agency size. 

3-31
 
However, the selection probabilities of the elder care provider agencies were adjusted to 

account for the fact that there was deliberate oversampling in anticipation of many non-existent or 

ineligible agencies, since it was not possible to construct a completely reliable frame. 

Agency Nonresponse Adjustments (Sentinel Agencies) 

The base weights are unbiased weights that inflate the sample data to population levels. 

Nonresponse in the study results in losses in the sample data that must be compensated for in the weights. 

In this case, the sentinel agency weights must be adjusted to compensate for the reduction in sample size. If 

nonresponse occurs at random, such adjustments are unbiased; however, nonresponse almost never occurs 

randomly. Consequently, such adjustments are typically made within classes that are internally as 

homogeneous as possible with respect to the agency characteristics. Thus, nonresponse adjustments are 

used to attenuate the biases that result from the likelihood that reports supplied by the nonrespondents (if 

they had been obtained) would have been different from those of the respondents. 

Sentinel Weights 

Because an equal probability scheme was used to select the sentinels, within each agency the 

sentinel base weight for each participating sentinel is the simple ratio of number of eligible sentinels divided 

by the number of participating sentinels. The sentinel base weight was inflated by the rate of participation 

(or percentage of coverage). The rationale behind this is the assumption that a sentinel participating 50 

percent of the time would have witnessed twice as many elder abuse incidents if he/she had participated 100 

percent of the time. 

Sentinel Case-Level Weight 

There were 140 forms returned (after unduplication) by 74 reporting sentinels from 53 

agencies. Each form was assigned a sentinel case-level weight. The aggregate weight distribution by 

agency type, during the reporting period of 2 months, is presented in Table 3-10 for the sentinel case-level 

weights. 

3-32
 
Table 3-10. Aggregate sentinel case-level weights by PSU and agency type 

W 

Site ID Forms Aggregate percentage 

OBE (fielding Agency Reporting Reporting returned weight W within 

region order) County type* agencies sentinels (RR) (W) percentage OBE 

1 05 Bristol 03 1 1 9 6,628 7.6% 37.0% 

1 05 Bristol 05 1 1 2 165 0.2% 0.9% 

1 05 Bristol 07 2 3 3 1,856 2.1% 10.4% 

1 09 Mercer 05 1 1 1 232 0.3% 1.3% 

1 09 Mercer 07 2 3 3 1,418 1.6% 7.9% 

1 12 Fayette 07 2 3 3 867 1.0% 4.8% 

1 14 York 03 1 1 1 1,275 1.5% 7.1% 

1 14 York 07 2 5 9 5,168 5.9% 28.9% 

1 17 Delaware 05 3 5 9 299 0.3% 1.7% 

2 04 Pinellas 05 1 1 1 88 0.1% 0.5% 

2 04 Pinellas 07 1 1 3 565 0.6% 2.9% 

2 06 Madison 07 1 1 1 14,608 16.7% 76.3% 

2 10 Giles 07 1 1 2 2,093 2.4% 10.9% 

2 18 Cleveland 07 2 4 5 896 1.0% 4.7% 

2 20 Pulaski 02 1 1 1 48 0.1% 0.2% 

2 20 Pulaski 05 2 2 3 168 0.2% 0.9% 

2 20 Pulaski 06 1 2 3 570 0.7% 3.0% 

2 20 Pulaski 07 2 2 2 113 0.1% 0.6% 

3 03 Bay 04 1 3 5 1,571 1.8% 4.0% 

3 03 Bay 05 1 1 1 785 0.9% 2.0% 

3 03 Bay 07 1 1 1 1,087 1.2% 2.7% 

3-33
 
 

Table 3-10. Aggregate sentinel case-level weights by PSU and agency type (continued) 

W 

Site ID Forms Aggregate percentage 

OBE (fielding Agency Reporting Reporting returned weight W within 

region order) County type* agencies sentinels (RR) (W) percentage OBE 

3 08 St. Clair 07 1 1 1 327 0.4% 0.8% 

3 15 DuPage 07 2 2 5 25,388 29.1% 64.2% 

3 16 Presque Isle 07 1 1 2 8,222 9.4% 20.8% 

3 19 Platte 03 1 1 1 1,204 1.4% 3.0% 

3 19 Platte 07 1 1 3 972 1.1% 2.5% 

4 01 Maricopa 03 1 1 2 1,019 1.2% 9.5% 

4 01 Maricopa 05 3 4 5 765 0.9% 7.1% 

4 01 Maricopa 07 2 2 6 1,518 1.7% 14.1% 

4 02 Rusk 03 1 1 1 218 0.2% 2.0% 

4 02 Rusk 07 1 2 2 489 0.6% 4.6% 

4 07 San Diego 05 1 2 2 53 0.1% 0.5% 

4 07 San Diego 07 1 1 1 59 0.1% 0.5% 

4 11 Grayson 03 1 1 1 1,241 1.4% 11.5% 

4 11 Grayson 07 3 4 9 2,719 3.1% 25.3% 

4 13 Multnomah 03 1 5 27 2,329 2.7% 21.7% 

4 13 Multnomah 04 1 1 3 179 0.2% 1.7% 

4 13 Multnomah 07 1 1 1 153 0.2% 1.4% 

Total 53 74 140 87,356 100.0% 

* Agency Type Codes: 02=County Sheriffs 05=Hospitals

 03=Municipal Police 06=Banks

 04=Public Health Depts. 07=Elder Care Providers 

3-34
 
Weight Trimming 

It was observed that six forms (one from Madison County and five from Dupage County) 

contributed to nearly 46 percent of the aggregate weights; that is, the national estimate of unreported (not 

reported to APS) elder abuse incidents was heavily influenced by these six forms. 

When just a few cases contribute such a large proportion of the total weight, national 

estimates became very unstable; that is, they have high sampling error. Thus, it is desirable to consider 

reducing the size of these extreme weights before carrying out analyses. The very slight bias that this 

procedure introduces into the estimates is of little consequence compared to the gains in sampling precision 

that result from weight trimming. 

The next step was to determine suitable trimming factors to apply. The typical number of 

forms returned by sentinels from elder care providers (ECP) in metropolitan counties was determined, since 

sentinels from such agencies reported all six cases with extreme weights. The median number of reports 

per sentinel was found to be 0.41667. It was decided to adjust the weights of these six cases so that, after 

weighting, the average number of cases per sentinel did not exceed 0.41667. Under this criterion, four of 

the five cases from DuPage County received a trimming factor of 0.41667. The fifth case from DuPage 

and the one case from Madison County received trimming factors of 1.0 (i.e., no trimming was applied). 

Even after this trimming process, a few cases contributed a large proportion of the total 

weight. One case from Madison County contributes 20 percent of the total, 28 times as large as the mean 

weight. Some records dominate the estimates in the study because suitable size measures for the ECP 

agencies included on the sampling frames were not available. Any further attempt to trim the weights 

would likely have led to a significant underrepresentation of reports from sentinels in relatively large ECP 

agencies. We judged that further trimming might introduce significant biases into the results. 

Table 3-11 presents the aggregate weights of the reporting forms after weight trimming. 

3-35
 
Table 3-11. Aggregate weights attached to sentinel forms after weight trimming 

W 

Site ID Forms Aggregate percentage 

OBE (fielding Agency Reporting Reporting returned weight W within 

region order) County type agencies sentinels (RR) (W) percentage OBE 

1 05 Bristol 03 1 1 9 6,628 9.1% 37.0% 

1 05 Bristol 05 1 1 2 165 0.2% 0.9% 

1 05 Bristol 07 2 3 3 1,856 2.5% 10.4% 

1 09 Mercer 05 1 1 1 232 0.3% 1.3% 

1 09 Mercer 07 2 3 3 1,418 1.9% 7.9% 

1 12 Fayette 07 2 3 3 867 1.2% 4.8% 

1 14 York 03 1 1 1 1,275 1.7% 7.1% 

1 14 York 07 2 5 9 5,168 7.1% 28.9% 

1 17 Delaware 05 3 5 9 299 0.4% 1.7% 

2 04 Pinellas 05 1 1 1 88 0.1% 0.5% 

2 04 Pinellas 07 1 1 3 565 0.8% 2.9% 

2 06 Madison 07 1 1 1 14,608 20.0% 76.3% 

2 10 Giles 07 1 1 2 2,093 2.9% 10.9% 

2 18 Cleveland 07 2 4 5 896 1.2% 4.7% 

2 20 Pulaski 02 1 1 1 48 0.1% 0.2% 

2 20 Pulaski 05 2 2 3 168 0.2% 0.9% 

2 20 Pulaski 06 1 2 3 570 0.8% 3.0% 

2 20 Pulaski 07 2 2 2 113 0.2% 0.6% 

3 03 Bay 04 1 3 5 1,571 2.2% 6.2% 

3 03 Bay 05 1 1 1 785 1.1% 3.1% 

3 03 Bay 07 1 1 1 1,087 1.5% 4.3% 

3 08 St. Clair 07 1 1 1 327 0.4% 1.3% 

3 15 Dupage 07 2 2 5 11,026 15.1% 43.8% 

3 16 Presque Isle 07 1 1 2 8,222 11.3% 32.6% 

3 19 Platte 03 1 1 1 1,204 1.6% 4.8% 

3 19 Platte 07 1 1 3 972 1.3% 3.9% 

4 01 Maricopa 03 1 1 2 1,019 1.4% 9.5% 

4 01 Maricopa 05 3 4 5 765 1.0% 7.1% 

4 01 Maricopa 07 2 2 6 1,518 2.1% 14.1% 

4 02 Rusk 03 1 1 1 218 0.3% 2.0% 

4 02 Rusk 07 1 2 2 489 0.7% 4.6% 

4 07 San Diego 05 1 2 2 53 0.1% 0.5% 

4 07 San Diego 07 1 1 1 59 0.1% 0.5% 

4 11 Grayson 03 1 1 1 1,241 1.7% 11.5% 

4 11 Grayson 07 3 4 9 2,719 3.7% 25.3% 

4 13 Multnomah 03 1 5 27 2,329 3.2% 21.7% 

4 13 Multnomah 04 1 1 3 179 0.2% 1.7% 

4 13 Multnomah 07 1 1 1 153 0.2% 1.4% 

Total 53 74 140 72,994 100.0% 

3-36
 
3.10 Measuring Sampling Variability 

Because the statistics presented in this report are estimates of national and subgroup characteristics 

and population sizes, based on samples of reports and sentinels, there is a degree of uncertainty in them. 

Had by chance a different sample been drawn, somewhat different results would have been achieved. This 

uncertainty in the results is referred to as sampling variability, or sampling variance. The degree of 

sampling variability present as a result of using a sample can be assessed from the sample data itself. For 

a particular estimate from the study, the associated measure of sampling variability is known as the 

standard error. 

Because the study used a complex sampling design, conventional formulae for estimating sampling 

variability (that assume a simple random sampling procedure) are inappropriate. The standard errors 

presented in this report have been calculated using a technique known as jackknife replicated variance 

estimation. For a full presentation of the methods and properties of the jackknife procedure, see Wolter 

(1985) or Lehtonen and Pahkinen (1996). 

When data are collected as part of a complex sample survey, there is often no easy way to 

produce approximately unbiased and design-consistent estimates of variance. The variance of survey 

statistics, including means and proportions, using standard statistical packages such as SAS or SPSS, are 

inappropriate and usually too small. A class of techniques called replication methods provides a general 

method of estimating variances for the types of complex sample designs and weighting procedures usually 

encountered in practice. The replication approach selects subsamples repeatedly from the whole sample, 

calculates the statistic of interest for each of these subsamples, and then uses the variability among these 

subsample or replicate statistics to estimate the variance of the full sample statistics. There are different 

ways of creating subsamples from the full sample. The subsamples are called replicates and the statistics 

calculated from these replicates are called replicate estimates. 

Replication is not the only way to compute the variance of statistics from complex samples; 

however, replication is able to handle complex sampling designs, complex estimates, and complex 

weighting schemes. Replication can be used when other methods are not easily applicable. This method 

also has advantages even when other methods, such as Taylor series approximation, can be applied. 

3-37
 
One of the main advantages of the replication approach is its ease of use during analysis. The 

same estimation procedure is used for the full sample and for each replicate. The variance estimates are 

then readily computed by a simple procedure. Furthermore, the same procedure is applicable to statistics 

such as means, percentages, ratios, and correlations. These estimates can also be calculated for analytic 

groups or subpopulations. It is not necessary for the analyst to understand the sampling or estimation 

methods if the replicate weights are included with the data. 

The replication procedure used to estimate sampling variance for NEAIS data was a stratified 

jackknife procedure. The four OBE regions used as primary stratifiers in the sample design were used to 

define four strata for variance estimation purposes. Thus, within each stratum there were five county 

PSUs. A detailed description of variance procedures is included with the description of weighting in 

Appendix L. 

3.11 Interpreting Results in the Presence of Sampling Variability 

A common technique used to present and interpret statistical data that are subject to sampling 

variability is through the use of confidence bands. A 95 percent confidence band for an estimate is 

obtained by adding twice the standard error to the estimate of interest, to give the upper bound, and 

subtracting twice the standard error from the estimate of interest, to obtain the lower bound. The statistical 

interpretation of a 95 percent confidence band is that, if such a band were constructed from all possible 

samples that might have been selected, 95 percent of such bands would contain the true answer. 

If the confidence band for an estimate is wide, relative to the size of the estimate itself, then this 

indicates that there is considerable uncertainty as to what the true value actually is. If, however, the band 

is narrow, then there can be confidence that the estimate is close to the true answer. Thus, for example, 

consider an estimate that a certain population characteristic is at the 10 percent level. If the confidence 

band for this estimate ranges from 1 percent to 19 percent, we can have confidence that the true level is 

something below 20 percent, but cannot draw any other inference with confidence. If an estimate of 10 

percent is accompanied by a confidence band that ranges from 9 percent to 11 percent, then we can be 

confident that the true figure is little different from 10 percent. 

3-38
 
Because the NEAIS sampled a relatively small number of counties, agencies, and sentinels, for 

many of the rarer characteristics described in this report, the confidence bands are relatively wide, like in 

the first example given in the previous paragraph. When this has occurred, the estimates presented in the 

report are duly noted as having this characteristic. 

The width of the confidence band does depend to some extent upon the size of the estimate itself, 

but for a complex sample design such as this, there are several other factors involved as well. Thus two 

estimates of different characteristics, that happen to be of similar size, can well have quite different 

confidence bandwidths, and this happens in many cases for the results included in this report. A key factor 

that determines the width of the confidence interval is the extent to which the characteristic of interest 

varies from county to county, and from agency to agency and sentinel to sentinel in the non-APS sector of 

the study. Estimates for those characteristics that tend to vary little across these domains will tend to have 

smaller standard errors, and thus narrower confidence bands, than those characteristics that are highly 

variable across counties, agencies, and sentinels. 

3-39
 
4.1 

4. FINDINGS—INCIDENCE OF ABUSE AND NEGLECT OF THE ELDERLY 

Chapter Four presents the findings of the National Elder Abuse Incidence Study (NEAIS). 

First, the numbers of reports of abuse, neglect, and self-neglect of elders over 60 that are not reported are 

compared with those that are reported to official agencies. Two national incidence estimates of abuse and 

neglect of elders 60 years and older in domestic settings in 1996 are then calculated—one without selfneglect and one with self-neglect included. Then, characteristics of victims, reporters and perpetrators 

known to Adult Protective Services (APS) agencies are described. Abuse reported by sentinel agencies is 

presented next, with a focus on the characteristics of elderly victims and perpetrators. 

Comparison of Reported and Unreported Abuse and Neglect and Calculation of 

National Estimates of the Incidence of Abuse and Neglect During 1996 

Table 4-1 provides important data for calculating the national incidence of domestic abuse, 

neglect, and self-neglect of elderly people in the continental United States in 1996 (Hawaii, Alaska, and 

the U.S. territories were not included in the study). Numbers represent new unduplicated reports to 

agency sentinels (column one) and to APS agencies (column two) during 1996. Column three is the 

number of those reports to APS agencies that were substantiated after an investigation. Column four is 

the sum of columns one and three. Standard errors, representing 95 percent confidence intervals, are 

shown in parentheses for all figures. The standard errors of the estimates for APS agencies are relatively 

low because of the large number of actual reports received by those agencies (1,466), while the standard 

errors for the sentinel data are relatively large because of the smaller number of actual reports (140 after 

duplicates were removed). 

If a report on the same individual was obtained from both an APS agency and from a 

sentinel, the case was included in the APS total, but not in the sentinel totals. Consequently, the numbers 

shown in the table in column one represent only those individuals reported uniquely by sentinel agencies. 

The term “incident” is also used and represents a report for only one individual for the calendar year, 

regardless of how many times other episodes of abuse were reported for that person. Typically, APS data 

include more than one report during a year for some victims. Since the numbers routinely reported by the 

states for the APS agencies within their boundaries do not represent individuals, total counts of abuse and 

4-1
 
neglect based on such data will be higher than the unduplicated estimates presented in this report. 

Because there is no duplication in the NEAIS data, the terms “incident” and “elder” are used 

interchangeably. 

Table 4-1.	 National estimates of the incidence of abuse, neglect, and self-neglect of persons 60 years 

and older, 1996 (unduplicated) 

(1) 

Reported by 

Sentinels 

Estimated Number of Elderly1 

(2) 

Reported to 

APS 

(3) 

Reported to APS: 

Substantiated Only 

(4) 

Total: 

Columns 

(1) and (3) 

Total Abuse, Neglect and 

Self Neglect 

(Standard error) 

435,901 

(114,887) 

236,479 

(34,298) 

115,110 

(20,326) 

48.7% 

551,011 

(118,008) 

Total Abuse and Neglect 

(Standard error) 

378,982 

(117,758) 

151,408 

(18,999) 

70,942 

(11,881) 

46.9% 

449,924 

(119,512) 

Abuse 

(Standard error) 

355,218 

(116,875) 

95,761 

(15,579) 

47,069 

(9,814) 

49.2% 

402,287 

(116,084) 

Neglect2 

(Standard error) 

147,035 

(52,290) 

85,143 

(12,966) 

35,333 

(6,706) 

41.5% 

182,368 

(58,743) 

Self-Neglect 

(Standard error) 

81,635 

(21,966) 

113,573 

(28,907) 

57,345 

(15,350) 

50.5% 

138,980 

(24,232) 

1 Subtotals do not add to totals because more than one type of abuse was reported for some cases. 

2

 Includes abandonment. 

To arrive at the most accurate estimate of the national incidence of elder abuse and neglect 

in 1996, researchers added two numbers: reports submitted to APS agencies and substantiated by those 

agencies [column 3], and reports made by sentinels and presumed to be substantiated [column 1]. 

Sentinel reports are treated as substantiated incidents for three reasons. First, the sentinels were selected 

because they had frequent daily contact with the elderly and had the ability to identify abuse if they 

encountered it. Second, the sentinels were trained carefully to carry out this role in a rigorous manner, 

including having an “800” telephone contact to call with any questions about client eligibility or data 

4-2
 
collection. The third reason is that only those incidents the sentinels believed met the definition of elder 

abuse and neglect were reported. In contrast, APS agencies receive reports from any and all sources, all 

of which must be investigated and many of which are not substantiated. 

Two separate incidence estimates are calculated—one without self-neglect and one with selfneglect included: 

Estimated Incidence of Elder Abuse and/or Neglect in 1996 

The best national estimate is that a total of 449,924 elderly persons, aged 60 and over, 

experienced abuse and/or neglect in domestic settings in 1996. Of this total, 70,942 (16 percent) were 

reported to and substantiated by APS agencies, but the remaining 378,982 (84 percent) were not reported 

to APS. From these figures, one can conclude that over five times (5.3) as many new incidents of abuse 

and neglect were unreported than those that were reported to and substantiated by APS agencies in 1996. 

The standard error suggests that nationwide as many as 688,948 elders or as few as 210,900 elders could 

have been victims of abuse and/or neglect in domestic settings in 1996. This range indicates that between 

1.7 and 9.0 times as many elders were abused and neglected and not reported to APS agencies as were 

reported to and substantiated by APS agencies. 

Estimated Incidence of
 

Elder Abuse, Neglect, and/or Self-Neglect in 1996
 

The best national estimate is that a total of 551,011 elderly persons, aged 60 and over, 

experienced abuse, neglect, and/or self-neglect in domestic settings in 1996. Of this total, 115,110 (21 

percent) were reported to and substantiated by APS agencies, with the remaining 435,901 (79 percent) not 

being reported to APS agencies. One can conclude from these figures that almost four times (3.8) as 

many new incidents of elder abuse, neglect, and/or self-neglect were unreported than those that were 

reported to and substantiated by APS agencies in 1996. The standard error suggests that nationwide as 

many as 787,027 elders or as few as 314,995 elders could have been abused, neglected, and/or selfneglecting in domestic settings in 1996. This range indicates that between 1.4 and 6.2 times as many 

elders were abused, neglected, and/or self-neglecting and not reported to APS as were reported to and 

substantiated by APS agencies. 

4-3
 
4.2 

Table 4-1 also shows the incidence of abuse and neglect by category: abuse only, including 

physical, sexual, emotional, and financial; neglect by caretakers (including abandonment); and selfneglect. More than three times as many incidents of abuse were observed by sentinels as were reported to 

APS. Self-neglect, on the other hand, was more commonly reported to APS agencies, at a rate of 1.4 to 1. 

Nearly one-half of all the incidents reported to APS (48.7%) were substantiated overall. Cases of neglect 

were somewhat less likely to be substantiated than other forms of abuse or neglect (41.5%). 

Please note: Throughout the following discussion of the NEAIS findings, there is frequent 

reference to “confidence bands,” as described on pages 3-37 and 38 of this report. This is an important 

and appropriate way of communicating information to the reader about the degree of certainty for specific 

data findings. While asterisks (*) are used in the tables included in this chapter to signify wide 

confidence bands, the actual numerical standard errors for all data elements for each table are included in 

Appendix M. 

Abuse Reported by APS Agencies 

Outcomes of Investigations 

As noted above, the total (unduplicated) estimated number of domestic elder abuse, neglect, 

and/or self-neglect reports investigated by APS agencies during 1996, nationwide, was 236,479. Each 

APS agency utilized the investigation process and criteria already in place in that state for determining 

whether a report was substantiated. Of these total reports, 115,110 (or nearly one-half – 48.7 percent) 

were substantiated after investigations, while almost another two-fifths (39.3 percent) were 

unsubstantiated, as shown in Figure 4-1on the next page. In addition, nearly one-tenth (8.2 percent) of the 

reports were still under investigation at the end of 1996, and a small portion of the reports (3.8 percent) 

had other outcomes (e.g., the alleged victim died, refused an investigation, could not be located, or had 

moved out of the area).

 It should be noted that an APS agency’s determination of non-substantiation of a report of 

suspected abuse or neglect does not conclusively mean that abuse or neglect did not happen. Rather an 

unsubstantiated report can mean that the level of proof required by that state was not sufficiently met, 

despite indications that abuse or neglect may have occurred (e.g., there is a reason to suspect abuse or 

neglect). 

4-4
 
Under 

investigation

8% 

Other 

4% 

Figure 4-1. Outcomes of APS investigations of domestic elder abuse, neglect, and self-neglect 1 

Substantiated 

49% 

Unsubstantiated
 

39%
 

Outcomes Estimated number

 of reports 

Substantiated 115,110 

Unsubstantiated 92,796 

Still under investigation 19,440 

Other 8,976 

Total 236,322 

1

 Unduplicated estimate of elderly victims reported to APS agencies, 1996. 

Figure 4-2 shows substantiated and unsubstantiated reports by Office of Business Economics 

(OBE) Region. The largest number of incidents was reported in Region IV, the Western United States. A 

total of 95,875 incidents (weighted and annualized), or 40 percent of the national total, were supplied by 

APS agencies from this region. The West also had the highest rate of substantiation, 58.8 percent. 

Region III, the Central United States, had the next highest proportion of substantiated incidents (57.2 

percent). Region II, in the Southeast, had the lowest substantiation rate of the four regions, 30.3 percent. 

Keeping in mind that these regions are equal in total population, the West clearly leads the other areas of 

the country on a per capita basis in total reports of elder abuse and neglect and rates of substantiation. 

This may be due to a heightened awareness of elder abuse in this part of the country and this possibility 

warrants further study. 

4-5
 
Figure 4-2. Substantiated and unsubstantiated reports to APS/aging agencies by OBE region 

120000
 

100000
 

80000
 

60000
 

40000
 

20000
 

0 

Region I
 Region II
 Region III
 Region IV
 

Substantiated 14996
 17566
 26251
 56296

Unsubstantiated* 21695
 40385
 19641
 39489

Total 36691
 57951
 45892
 95785

*Includes cases under investigation and other cases with undetermined outcomes. 

4-6
 
Substantiated Reports of Abuse by Others 

As shown in Table 4-2, nearly one-half of substantiated reported incidents (48.7 percent) 

involved neglect, while slightly more than one-third (35.4 percent) were concerned with 

emotional/psychological abuse. Next, financial/material exploitation accounted for somewhat less than 

one-third (30.2 percent) of all substantiated reports. Approximately one-fourth (25.6%) of substantiated 

reports involved physical abuse. Findings on abandonment (3.6 percent), sexual abuse (0.3 percent), and 

other types of maltreatment (1.4 percent) had wide confidence bands. 

Table 4-2. Types of elder maltreatment substantiated by APS agencies. 

Maltreatment Number of Reports Percentages1 

Neglect 34,525 (48.7%) 

Emotional/psychological abuse 25,142 (35.4%) 

Financial/material exploitation 21,427 (30.2%) 

Physical abuse 18,144 (25.6%) 

Abandonment 2,560* (3.6%) 

Sexual abuse 219* (0.3%) 

Other 994* (1.4%) 

Total incidents 70,942** 

1 Estimated number of substantiated reports of domestic elder abuse with each type of maltreatment, 1996. Cases of selfneglect only are excluded. 

* The confidence band for this number is wide, relative to the size of the estimate. The true number may be close to zero 

or much larger than the estimate. 

** Total incidents do not equal totals across abuse categories because more than one substantiated type of abuse was often 

reported for an incident. 

Reporters of Substantiated Abuse by Others 

As presented in Table 4-3, family members of victims reported one-fifth (20.0 percent) of 

the 70,942 substantiated reports of domestic elder abuse and neglect in 1996. Hospitals (17.3 percent) 

and police/sheriff's departments (11.3 percent) followed. In addition, in-home service providers (9.6 

percent), friends/neighbors (9.1 percent), victims (8.8 percent), and physicians, nurses, and clinics (8.4 

percent) each accounted for slightly less than one-tenth of the substantiated domestic elder abuse reports 

where elders were abused by perpetrators. Further, banks (0.4 percent) and public health departments 

4-7
 
(0.1 percent) were responsible for small percentages of the substantiated reports, but the numbers of their 

reports are negligible and may not be much greater than zero. 

Table 4-3. Reporters of substantiated abuse by others 

Number of reports Number of reports 

Reporter (percentage)1 Reporter (percentage)1 

Family members 14,169 (20.0%) Physician, nurse, 5,925 (8.4%) 

clinic 

Hospital 12,290 (17.3%) Out-of-home 

service provider 3,716 (5.2%) 

Police/sheriff 8,031 (11.3%) Bank 305* (0.4%) 

In-home service 6,816 (9.6%) Public health 35* (0.1%) 

Provider department 

Friend/neighbor 6,476 (9.1%) Other 10,729 (15.1%) 

Victim 6,216 (8.8%) 

Total 70,942** 

1 Estimated number of substantiated elder abuse reports, by type of reporter 1996. Cases of self-neglect only are excluded. 

* The confidence band for this number is wide, relative to the size of the estimate. The true number may be close to zero or much larger than the 

estimate. 

** Respondents recorded one or more reporters for each incident. 

Reporters of Substantiated Reports of Self-Neglect 

As shown in Table 4-4, hospitals (19.8 percent) and friends/neighbors (19.1 percent) were 

the most frequent reporters of the substantiated reports of self-neglect in 1996, followed by 

police/sheriff’s department (11.7 percent), and family members (6.5 percent). Other reporters, who 

account for 26.5 percent, involved a long list including churches, apartment managers, fire departments, 

landlords, residential facilities, utility companies, and anonymous reporters. (Some incidents were 

reported by more than one reporter.) 

4-8
 
Table 4-4. Reporters of substantiated reports of self-neglect1 

Number of reports Number of reports 

Reporter (percentage) Reporter (percentage) 

Hospital 8,727 (19.8%) Out-of-home 3,431* (7.8%) 

service provider 

Friend/neighbor 8,433 (19.1%) Victim 624* (1.4%) 

Police/sheriff 5,152 (11.7%) Bank 247* (0.6%) 

Family member 2,877 (6.5%) Public health 0* (0.0%) 

department 

In-home service 5,435* (12.3%) Other 11,685 (26.5%) 

Provider 

Physician, nurse, 5,076* (11.5%) 

clinic 

Total 44,168** 

1 Estimated number of substantiated incidents of self-neglect by type of reporter. 

* The confidence band for this number is wide, relative to the size of the estimate. The true number may be close to zero or much larger than the 

estimate. 

** Total number of substantiated incidents of self-neglect includes one or more reports by type of reporter. 

4-9
 
Three Most Frequent Reporters for Each Maltreatment Type 

The three most frequent reporters for each type of substantiated maltreatment with 

perpetrators (i.e., excluding self-neglect) are shown in Table 4-5. 

Table 4-5. Three most frequent reporters for each maltreatment type1 

Reporter 

Family member 

Neglect 

24.3% 

Emotional/ 

Psychological 

Financial/ 

material 

14.0% 

Physical Abandonment Sexual abuse 

Hospital 16.1% 17.9% 14.2% 11.8% 56.2%* 

Friend/neighbor 14.1%* 15.0% 12.4%* 

Victim 17.8% 

In-home service 16.9%* 23.9% 100.0% 

Police/sheriff 24.3% 

Physician, nurse, 

clinic 

17.6%* 

1 This table is based on estimated 70,942 substantiated reports of domestic elder abuse, where perpetrators maltreated elders in 1996. The 

substantiated reports of self-neglect are not included. 

* The confidence band for this number is wide, relative to the size of the estimate. The true number may be close to zero or much larger than the 

estimate. 

Neglect. Family members (24.3 percent), hospitals (16.1 percent), and friends/neighbors 

(14.1 percent) together accounted for more than half of the reports of neglect substantiated in 1996. 

Emotional/psychological abuse. Hospitals (17.9 percent), victims (17.8 percent), and inhome service providers (16.9 percent) were the three most frequent reporters of substantiated 

emotional/psychological abuse. 

Financial/material exploitation. Friends/neighbors (15.0 percent), hospitals (14.2 percent), 

and family members (14.0 percent) were the three most frequent reporters of substantiated 

financial/material exploitation. 

4-10
 
Physical abuse. Police/sheriff's departments (24.3 percent), in-home service providers (23.9 

percent), and hospitals (11.8 percent) were the most frequent reporters of the substantiated reports of 

physical abuse. 

Abandonment. Hospitals alone accounted for 56.2 percent of the substantiated reports of 

abandonment. In addition, physicians, nurses, and clinics (17.6 percent) and friends/neighbors (12.4 

percent) constituted the second and third most frequent reporters of the substantiated reports of 

abandonment, respectively. 

Sexual abuse. In-home service providers reported all of the substantiated reports of sexual 

abuse. 

Outcomes of Investigations for Different Types of Maltreatment 

As noted earlier, the overall substantiation rate of domestic elder abuse and neglect reports 

was 48.7 percent in 1996. Table 4-6 on the next page presents the outcomes of investigations for different 

types of maltreatment. As the table shows, slightly more than three-fifths (61.9 percent) of the reports of 

physical abuse were substantiated after investigations, and this type of maltreatment marked the highest 

substantiation rate. Abandonment recorded the second highest substantiated rate, with somewhat over 

one-half (56.0 percent) of the reports of abandonment substantiated. Emotional/psychological abuse 

followed closely with the third highest substantiation rate (54.1 percent). Next, financial/material 

exploitation (44.5 percent) and neglect (41 percent) shared similar substantiation rates. The “other” 

category includes persons with unclassified abuse, some of whom died. 

4-11
 
Table 4-6. Outcomes of investigations for different types of maltreatment1 

Maltreatment type Substantiated Unsubstantiated 

Still under 

Investigation Other 

Physical abuse 61.9% 33.6% 3.9%* 0.5%* 

Abandonment 56.0% 36.8% 4.5%* 2.7%* 

Emotional/psychological 54.1% 31.6% 12.9% 1.4%* 

Financial/material 44.5% 35.8% 13.4% 6.3%* 

Neglect 41.0% 44.6% 7.7% 6.1% 

Sexual abuse 7.4%* 84.8%* 0.0% 7.8%* 

Other 89.0% 11.0% 0.0% 0.0% 

1 Based on estimated 151,408 weighted reports of "abuse by others" category. 

* The confidence band for this number is wide, relative to the size of the estimate. The true number may be close to zero or much larger than the 

estimate. 

4-12
 
4.3 Characteristics of Elderly Victims, Reported to APS 

Ages of Elder Abuse Victims for Selected Types of Maltreatment 

An analysis of substantiated reports of domestic elder abuse (where perpetrators were 

present) reveals information about the ages of victims of different types of maltreatment as shown in 

Figure 4-3. Nationwide in 1996, approximately 23% of elders 60 and over were age 60-64. This 

proportion declines gradually in each 5-year interval until ages 85+, representing only 8.5 percent of 

elders. 

Figure 4.3 Ages of elder abuse victims for selected types of maltreatment1 

80.0%
 

60.0%
 

40.0%
 

20.0%
 

0.0%
 Neglect Emotional Physical Financial Abandonment 

* * 60 to 64 2.3% 10.8% 5.5% 3.1% 18.4%

65 to 69 5.9% 9.5% 9.8% 9.4% 0.0%

70 to 74 24.1% 14.1% 17.8% 10.8% 3.0%

75 to 79 15.9% 24.3% 23.3% 28.7% 58.8%

80 or older 51.8% 41.3% 43.7% 48.0% 19.8%

Percent of victims 48.7% 35.4% 25.7% 29.9% 2.9%* 

experiencing abuse 

1

Based on estimated 70,556 substantiated incidents of elder abuse. Some entries have missing values 

* The confidence band for these numbers is wide, relative to the size of the estimate. The true number may be close to zero or much larger than 

the estimate. 

4-13
 
Neglect. More than one-half (51.8 percent) of the victims of neglect were 80 years of age 

and older in 1996, while almost one-fourth (24.1 percent) were between 70 and 74 years of age. Next, 

those who were between 75 and 79 years of age and those who were between 65 and 69 years of age 

accounted for 15.9 percent and 5.9 percent, respectively. Only 2.3 percent of neglect victims were 

between 60 and 64 years of age, but this has a wide confidence band. 

Emotional/psychological abuse. Like neglect, the largest age group of victims of 

emotional/psychological abuse was elders who were 80 years of age and older (41.3 percent). In addition, 

almost one-fourth of the victims (24.3 percent) were between 75 and 79 years of age, and another oneseventh (14.1 percent) were between 70 and 74. Next, two other age groups each accounted for 

approximately one-tenth of the victims, as follows: the 60 to 64 group (10.8 percent) and the 65 to 69 

group (9.5 percent). 

Physical abuse. More than two-fifths (43.7 percent) of the victims of physical abuse were 

80 years of age and older, while somewhat less than one-fourth (23.3 percent) were between 75 and 79 

years of age. In addition, those who were between 70 and 74 and between 65 and 69 accounted for 17.8 

percent and 9.8 percent, respectively. Only 5.5 percent of physical abuse victims were between 60 and 64 

years old, but this has a wide confidence band. 

Financial/material exploitation. Nearly one-half (48.0 percent) of the victims of 

financial/material exploitation were 80 years of age and older, while another 28.7 percent were between 

75 and 79 years of age. Next, the elderly victims between 70 and 74 years of age and those between 65 

and 69 accounted for 10.8 percent and 9.4 percent, respectively. Victims between 60 and 64 years old 

accounted for 3.1 percent of financial/material exploitation. 

Abandonment. The victims of abandonment appear to be somewhat younger than the 

victims of other types of maltreatment, as the percentages in the table show; however, because most of 

these analytical findings have wide confidence bands it is not possible to confirm what the table suggests. 

4-14
 
Incomes of Elder Abuse Victims 

The APS data form asked for an estimate of the income of the maltreated elder and spouse (if 

any). For 71 percent of the elders, the APS worker was able to make this estimate, while in 29% percent 

of the reports, the worker was not able to do so. Due to the sensitivity of the issue and the focus on 

recording other important information, the APS worker did not attempt to gather additional information 

on income from other sources. An analysis of 53,667 substantiated reports of domestic elder abuse 

(excluding reports of self-neglect), for which income information was available, was performed. The data 

are shown in Table 4-7. 

Table 4-7. Incomes of elder abuse victims for selected types of maltreatment1 

Income 

category Neglect 

Emotional/ 

psychological Physical abuse 

Financial/ 

material Abandonment 

Less than $5,000 2.4%* 6.2%* 7.6%* 1.9%* 0.0% 

$5,000-$9,999 66.8% 37.8% 49.5% 46.0% 96.1% 

$10,000-$14,999 21.4% 31.0% 18.5%* 29.8% 3.9%* 

15,000 and up 9.5% 25.0% 24.5%* 22.4% 0.0% 

Total 100% 100% 100% 100% 100% 

Percentage of 

victims 

experiencing 

abuse 

51.8% 34.9% 23.9% 30.7% 3.5%* 

1 Based on an estimated 53,667 substantiated incidents of elder abuse. Income was missing for 28.8 percent of reports. 

* The confidence band for this number is wide, relative to the size of the estimate. The true number may be close to zero or much larger than the 

estimate. 

Neglect. Two-thirds (66.8 percent) of the victims of neglect had annual incomes that were 

between $5,000 and $9,999, and another slightly more than one-fifth (21.4 percent) had annual incomes 

that fell between $10,000 and $14,999. In addition, the annual incomes of nearly one-tenth (9.5 percent) 

of neglect victims were $15,000 or higher. 

Emotional/psychological abuse. Somewhat less than two-fifths (37.8 percent) of the 

victims had incomes that were between $5,000 and $9,999, while nearly one-third (31.0 percent) were 

those whose incomes fell between $10,000 and $14,999. In addition, exactly one-fourth (25.0 percent) of 

4-15
 
 

the victims of emotional/psychological abuse had incomes of $15,000 or more. All of these findings were 

statistically significant. 

Physical abuse. Like the victims of neglect and emotional/psychological abuse, the largest 

portion (49.5 percent) of physical abuse victims had incomes between $5,000 and $9,999. All other 

findings on victims' incomes in this maltreatment category had wide confidence bands. 

Financial/material exploitation. Nearly one-half (46.0 percent) of the elder victims had 

incomes between $5,000 and $9,999, while almost one-third (29.8 percent) were those whose incomes fell 

between $10,000 and $14,999. In addition, slightly more than one-fifth (22.4 percent) of financial/ 

material exploitation victims had incomes that were $15,000 or more. 

Abandonment. Almost all victims (96.1 percent) of abandonment had incomes that were 

between $5,000 and $9,999, and this finding was statistically significant (p< .05). 

Sex of Elder Abuse Victims 

Nationwide, females comprised 57.6 percent of the elderly population over 60 years old in 

1996; males were 42.4 percent. Consequently, percentages of females over 58% in any category may 

indicate that they are over represented; lower proportions do not.1 

Neglect was the most frequent type of maltreatment, affecting 48.7 percent of all victims of 

elder abuse, as presented in Figure 4-4. More than one-half (60.0 percent) of the victims of neglect were 

female elders, while the remaining neglect victims (40.0 percent) were male elders. Next, 

emotional/psychological abuse was the second most frequent type, with 35.4 percent of the victims. Data 

show that about three-quarters (76.3 percent) of the victims of this type of maltreatment were female 

elders, while the remaining 23.7 percent were male elders. Emotional abuse is the category of abuse in 

which women are most heavily over-represented compared to their portion of the total elderly population 

(76.3 vs. 57.6 percent). 

1 Source: U.S. Bureau of the Census, Population Paper Listing 57. 

4-16
 
100.0%

50.0%

0.0% 

Neglect Emotional/ Physical Financial/ Abandonment 

Male 40.0% 23.7% 28.6% 37.0% 62.2% 

Female 60.0% 76.3% 71.4% 63.0% 37.8% 

Percent of 48.7% 35.4% 25.6% 30.2% 3.6%
 

victims
 

experiencing
 

abuse
 

Financial/material exploitation was the third most frequent type involving 30.2 percent of the 

victims. Female elders were victims of financial/material exploitation somewhat more than their 

proportion of the elder population (63.0 percent vs. 57.6 percent), while male elders were victims of 

exploitation 37.0 percent of the time. Physical abuse was the fourth most frequent type of elder 

maltreatment, accounting for 25.6 percent of all victims. Over two-thirds (71.4 percent) of the victims of 

physical abuse were female elders, while the remaining one-third (28.6 percent) were male elders. 

Physical abuse is the second category in which women are most over represented as victims compared to 

overall population statistics (71.4 vs. 57.6 percent). 

Abandonment only accounted for 3.6 percent of all victims of abuse, but men were 

disproportionally represented compared with their proportion of the elderly population (62.2 vs. 42.4 

percent). 

Figure 4-4. Sex of elder abuse victims for selected types of maltreatment 

Race/Ethnicity of Elder Abuse Victims 

Figure 4-5 on the next page presents the race/ethnicity of elder abuse victims for selected 

types of maltreatment. Nationwide in 1996 among those 60 and older, 84 percent were White, 8.3 percent 

were Black, 5.1 percent were Hispanic, 2.1 percent were Asian or Pacific Islander, and 0.4 percent were 

4-17
 
American Indian or Alaskan Natives. White elders account for 79.0 percent of the victims of neglect, 

which was the most frequent type of maltreatment, affecting 48.7 percent of all abuse victims. Black 

elders accounted for 17.2 percent of neglect victims. Elders from other racial/ethnic groups, however, 

were underrepresented among the victims of neglect, as shown in Figure 4-5. Emotional/psychological 

abuse was the second most frequent type of maltreatment, with 35.5 percent of victims. Over four-fifths 

(82.8 percent) of the victims of this type of maltreatment where white elders, while 14.1 percent were 

black. Physical abuse was the third most frequent type of elder maltreatment, with 25.6 percent of abuse 

victims. White elders represented 86.0 percent of victims of physical abuse, while black elders comprised 

approximately 9.0 percent. Elders from other racial/ethnic categories were underrepresented. 

Financial/material exploitation was the fourth most frequent type of maltreatment, with 30.2 

percent of all elder abuse victims. The proportion of white victims of this type of elder maltreatment was 

83.0 percent. Black elders comprised 15.4 percent of abuse victims of this type. Again, elders from other 

racial/ethnic groups were underrepresented among victims. Abandonment accounted for only 3.6 percent 

of all victims of elder abuse. Interestingly, the percentages of white victims (41.3 percent) and black 

victims (57.3 percent) for this type of abuse were very close, but with the black population significantly 

over-represented than its proportion of the elderly population (8.3 percent). In addition, abandonment 

was the only type of abuse for which the racial/ethnic breakdown data had wide confidence bands in 

every category. 

4-18
 
Figure 4-5. Race/ethnicity of elder abuse victims for selected types of maltreatment 

100.0%

90.0%

80.0%

70.0%

60.0%

50.0%

40.0%

30.0%

20.0%

10.0%

0.0%

Neglect Emotional Physical Financial Abandonment * 

White 79.0% 82.8% 86.0% 83.0% 41.3%

* * * Black 17.2% 14.1% 9.0% 15.4% 57.3%

* * * * * Hispanic 2.7% 0.6% 0.9% 0.8% 1.4%
 

Asian/Pacific Islander
 0.3% 0.4% 0.4% 0.2% 0.0%
 

Am. Indian/ Alaskan Native
 0.0% 0.0% 0.2% 0.0% 0.0%
 

Other/Unknown
 0.8% 2.1% 3.6% 0.6% 0.0% 

Percent of victims 48.6% 35.5% 25.6% 30.2% 3.6% 

experiencing abuse 

*The confidence band for these numbers is wide, relative to the size of the estimate. The true number may be close to zero or much larger than 

the estimate. 

4-19
 
 

Physical and Mental Frailty 

Elderly people with physical and mental frailties are more likely to be vulnerable to abusive 

behavior. Nationwide, approximately 15 percent of older people are depressed at any one time; 10 

percent suffer from some form of dementia, and approximately 14 percent have difficulties with one or 

more activities of daily living.2 While rates of depression remain fairly stable across the adult life span, 

physical and mental frailties increase, especially among those over the age of 85. It has long been 

suspected that these impairments are more common among elders who are victims of abuse and neglect, 

although no such estimates are available. The NEAIS obtained estimates of these frailty measures. 

Self-Care Ability. The data suggest that a large proportion—about three out of four--of elder 

abuse and neglect victims suffer from physical frailty. Approximately one half (47.9 percent) of the 

substantiated incidents of abuse and neglect involved elderly persons who were not physically able to care 

for themselves. Another 28.7 percent of elders were only somewhat able to care for themselves, while 

only about one in five (22.9 percent) elders were judged able to care for themselves, as shown below. 

Table 4-8. Ability to Care for Self Physically (APS)1 

Characteristics of Maltreated 

Elders 

Not Able to Care for Self 

Number of 

Estimated Reports 

34,009 

Percentage 

47.9 

Somewhat Able to Care for Self 20,380 28.7 

Able to Care for Self 16,259 22.9 

Don’t Know, Cannot Determine 294* 0.4* 

1

Based on an estimated 70,942 substantiated cases of abuse, excluding self-neglecting elders. 

*The confidence band for these numbers is wide, relative to the size of the estimate. The true number may be close to zero or much 

larger than the estimate. 

Confusion. Six out of 10 elder abuse victims experienced some degree of confusion, which 

represents a high degree of mental impairment among this group of elders. Approximately one third (31.6 

percent) of these elders were very confused or disoriented. Another more than one quarter (27.9 percent) 

was sometimes confused, while 38.7 percent were not confused, as shown in Table 4-9 on the next page. 

2

 Disability in the United States: Prevalence and causes, 1992, U.S. Department of Education Cases and Rehabilitative Services, July 1996, Table 

3, p.75; and U.S. Census Bureau Report on Disability Status of Persons 65 Years and Older in 1994-95, November 1997. 

4-20
 
Table 4-9. Confusion (APS)1 

Characteristics 

Elders 

Not Confused 

of Maltreated Number of 

Estimated Reports 

27,425 

Percentage 

38.7 

Sometimes Confused 19,820 27.9 

Very Confused, Disoriented 22,417 31.6 

Don’t Know, Cannot Determine 1,279* 1.8* 

1

Based on an estimated 70,942 substantiated cases of abuse, excluding self-neglecting elders. 

*The confidence band for these numbers is wide, relative to the size of the estimate. The true number may be close to zero or much 

larger than the estimate. 

Depression. The data on depression among victims of abuse and neglect are less conclusive, but 

do suggest a somewhat smaller problem than self-care ability and confusion. In 21.1 percent of the 

incidents of substantiated elder abuse and neglect, the APS agency was not able to determine whether 

depression was present or not. About 45 percent of the total group had some degree of depression (6.3 

percent severe and 37.3 percent moderate) and about one third (35.4 percent) were not depressed. 

Table 4-10 Depression (APS)1 

Characteristics 

Elders 

Not Depressed 

of Maltreated Number of 

Estimated Reports 

25,051 

Percentage 

35.4 

Moderate Depression 26,407 37.3 

Severe Depression 4,424 6.3 

Don’t Know, Cannot Determine 14,915 21.1 

1

Based on an estimated 70,797 substantiated cases of abuse, excluding self-neglecting elders. 

4-21
 
4.3.1 Characteristics of Perpetrators of Domestic Elder Abuse 

Sex of Perpetrators of Elder Abuse 

An analysis of the substantiated incidents of elder abuse reveals that 52.5 percent of the 

incidents involved male perpetrators, while the remaining 47.5 percent were female perpetrators, as 

shown below in Figure 4-6: 

Figure 4-6. Sex of perpetrators of elder abuse 

Female 

perpetrators Male

47% perpetrators 

53% 

Total: 59,979; male perpetrators: 31,499; female perpetrators: 28,450. 

Neglect was the most frequent type of maltreatment committed, as presented in Table 4-11. 

Slightly more than one-half (52.4 percent) of the perpetrators of neglect were female, while the remaining 

perpetrators (47.6 percent) were male. Emotional/psychological abuse was the second most frequent type 

of maltreatment. Data show that just over one-half of the perpetrators were male (60.1 percent) while the 

remainder were female (39.9 percent). Financial/material exploitation was the next most frequent type of 

abuse perpetrated. Perpetrators of this type of abuse were approximately 60 percent male, while the 

remaining were females. Almost two-thirds of the perpetrators of physical abuse were males (62.6 

percent) while the remaining one-third (37.5 percent) were females. Abandonment was predominately 

perpetrated by males (83.4%) while the remainder was females. Interestingly, neglect is the only type of 

maltreatment that was committed with approximately equal frequency by females and males. For the 

remainder of the maltreatment types, males clearly were more likely to commit abuse and neglect. 

4-22
 
Table 4-11. Sex of perpetrators of domestic elder abuse for selected types of maltreatment1 

Sex Neglect 

Emotional/ 

Psychological Physical abuse 

Financial/ 

material Abandonment 

Male 47.6% 60.1% 62.6% 59.0% 83.4% 

Female 52.4% 39.9% 37.4% 41.0% 16.6%* 

Total 100% 100% 100% 100% 100% 

Percentage 

of victims
 

experiencing
 

47.4% 35.8% 27.0% 30.8% 4.2%*
 

abuse.
 1 Based on an estimated 59,672 substantiated incidents of elder abuse. Some entries have missing values. 

*The confidence band for these numbers is wide, relative to the size of the estimate. The true number may be close to zero or much larger than 

the estimate. 

Ages of Perpetrators of Domestic Elder Abuse 

The distribution of perpetrators of domestic abuse by age is shown in Figure 4-7 on the next 

page. The majority of elder abuse perpetrators were younger than 60 years of age. Approximately twothirds (65.8 percent) of the perpetrators of elder abuse were persons who were 59 years old and younger, 

while approximately 25 percent of the perpetrators were persons who were 70 and older. In addition, 

slightly less than 10 percent of the perpetrators were between the ages of 60 and 69. 

4-23
 
Figure 4-7. Ages of perpetrators of domestic elder abuse 

80 or older 

14% 40 or less 

27% 

70 to 79 

12% 

60 to 69 

8% 

41 to 59 

39% 

The ages of the perpetrators of domestic elder abuse reveal an interesting relationship. The 

majority of perpetrators, as shown above, are in the youngest age groups; however, there is a relatively 

large proportion of perpetrators in the oldest age group. This relationship becomes more visible when the 

ages of perpetrators are examined for selected types of maltreatment. Table 4-12 presents this 

relationship. 

Table 4-12. Age of perpetrators of domestic elder abuse for selected types of maltreatment1 

Emotional/ Financial/ 

Age 

40 and under 

Neglect Psychological Physical abuse material Abandonment 

20.1% 34.3% 20.3% 45.1% 1.4%* 

41 to 59 34.2% 42.4% 41.9% 39.5% 67.5% 

60 to 69 9.2%* 10.4%* 8.1%* 3.4%* 0.0%* 

70 to 79 18.9%* 4.8%* 12.4%* 1.6%* 1.5%* 

80/older 17.7% 8.2% 17.4%* 10.4%* 29.6%* 

Total 

Percentage 

100% 100% 100% 100% 100% 

48.5% 34.8% 26.9%* 30.2%* 4.3%* 

of victims 

experiencing 

abuse 

Based on an estimated 57,933 substantiated incidents of elder abuse. Some entries have missing values. 

*The confidence band for these numbers is wide, relative to the size of the estimate. The true number may be close to zero or much larger than 

the estimate. 

4-24
 

1 
For the majority of maltreatment types, the perpetrators are concentrated in two age groups-­

those younger than age 40 and those older than age 80. However, when the specific age groups are 

examined by type of abuse, no two types follow the same pattern. Perpetrators of neglect were relatively 

evenly distributed across all age groups. Approximately one-fifth (20.1 percent) of the perpetrators of 

neglect were younger than age 40, while one-third (34.2 percent) of the perpetrators were between the 

ages of 41 and 59. It is worth noting that confidence bands are such that values may not be much greater 

than zero for all except these two age groups. A small proportion (9.2 percent) of the perpetrators of 

neglect was between the ages of 60 and 69. Further, the age groups of 70 to 79 and 80 and older each had 

nearly one-fifth of the perpetrators (70 to 79, with 18.9 percent; 80 and older with 17.7 percent). 

Perpetrators of emotional/psychological abuse were concentrated among the younger age 

groups. Approximately one-third (34.3 percent) of the perpetrators of emotional/psychological abuse 

were younger than age 40 and 42.4 percent of the perpetrators were between the ages of 41 and 59. 

Again, it is only the younger age groups for which the data are significant. A small proportion (10.4 

percent) of the perpetrators of emotional/psychological abuse was between the ages of 60 and 69. The 

proportions of perpetrators of emotional/psychological abuse in other age categories were very small. Of 

the perpetrators of physical abuse, 41.9 percent were between the ages of 41 and 59. An additional 20.3 

percent were in the youngest age category—younger than 40. A small proportion of perpetrators of 

physical abuse was between the ages of 60 and 69, while 12.4 percent of the perpetrators were between 

the ages of 70 and 79. Last, 17.4 percent of the perpetrators of physical abuse were older than 80 years of 

age. 

Perpetrators of financial/material exploitation were generally concentrated in the youngest 

age categories. Approximately 45 percent of the perpetrators were below the age of 40, while an 

additional 39.5 percent of the perpetrators were between the ages of 41 and 59. In addition, 3.5 percent of 

the perpetrators of financial/material exploitation were between the ages of 60 and 69, and 1.6 percent of 

the perpetrators were between the ages of 70 and 79. Last, 10.4 of the perpetrators were older than 80 

years of age. For the older age groups of perpetrators, those older than 60, confidence bands are wide and 

values may not differ significantly from zero. Perpetrators of abandonment accounted for only 4.3 

4-25
 
percent of all perpetrators of elder abuse. Approximately two-thirds (67.5 percent) of the abandonment 

perpetrators were between the ages of 41 and 59, while the remainder were older than 80 years of age. 

The age categories of less than 40 and 70 to 79 each comprised about 1.5 percent of the perpetrators of 

abandonment. 

Race/Ethnicity of Perpetrators of Domestic Elder Abuse 

Approximately three-fourths (77.4 percent) of elder abuse perpetrators in the substantiated 

cases in 1996 were white, and somewhat less than one-fifth (17.9 percent) were black, as shown below in 

Figure 4-8; however, only small percentages of persons from other racial/ethnic groups were represented 

among the perpetrators of elder maltreatment. 

Figure 4-8. Race/ethnicity of perpetrators of domestic elder abuse* 

Other**

4% Hispanic 

1% Black
 

18%
 

White 

77% 

*Based on an estimated 44,168 substantiated incidents of elder abuse.
 

**Includes American Indian/Alaskan Native, Asian/Pacific Islander, and other/unknown.
 

Table 4-13 on the next page presents the race/ethnicity of perpetrators of domestic elder 

abuse for selected types of maltreatment. White perpetrators account for 76.6 percent of the perpetrators 

of neglect, while 20.4 percent of the perpetrators of neglect were black. Percentages of perpetrators of 

neglect from other racial/ethnic groups were very small, as shown in the table. 

4-26
 
Table 4-13. Race/ethnicity of perpetrators of domestic elder abuse for selected types of maltreatment1 

Race/ Emotional/ Financial/ 

Ethnicity Neglect Psychological Physical abuse material Abandonment 

White 76.6% 77.3% 83.0% 77.1% 34.4%* 

Black 20.4% 17.8%* 11.3%* 18.7%* 59.0%* 

Hispanic 0.8%* 0.8%* 1.4%* 0.8%* 1.4%* 

Asian/Pacific 0.3%* 0.5%* 0.3%* 0.2%* 0.0%* 

Islander 

Am. Indian/ 0.1%* 0.0%* 0.1%* 1.5%* 0.0%* 

Alaskan Native 

Other/unknown 1.9%* 3.6%* 3.8%* 1.7%* 5.2%* 

Percentage of 47.5% 35.4% 26.9% 31.0% 4.2%* 

total perpetrators 

1 Based on an estimated 59,517 substantiated incidents of elder abuse. Some entries have missing values. 

*The confidence band for these numbers is wide, relative to the size of the estimate. The true number may be close to zero or much larger than 

the estimate. 

Emotional/psychological abuse was the second most frequent type of elder maltreatment, 

with 35.4 percent of perpetrators involved with it. Over three-quarters (77.3 percent) of the perpetrators 

of this type of maltreatment were white, while 17.8 percent were black. Once again, percentages of 

perpetrators of emotional/psychological abuse from other racial/ethnic groups were very small. 

Financial/material exploitation was the next most frequent type of maltreatment under this analysis. The 

proportion of white perpetrators in this type of elder maltreatment was 77.1 percent. About 19 percent of 

the perpetrators of emotional/psychological abuse were black, and the perpetrators from other 

racial/ethnic populations were greatly underrepresented among the perpetrators of financial/material 

exploitation. 

Of the perpetrators of physical abuse, 83.0 percent were white, while black perpetrators 

accounted for 11.3 percent. The remaining racial/ethnic groups all comprised less than 5 percent of the 

perpetrators. Perpetrators of abandonment accounted for only 4.2 percent of all perpetrators of elder 

abuse. Just over one-half (59.0 percent) of the abandonment perpetrators were black, while one-third of 

the perpetrators (34.4 percent) were white. Hispanic elders accounted for 1.4 percent of the victims of 

abandonment. Because of the high standard errors, the data overall should be regarded as tentative. 

4-27
 
Relationship of Perpetrators to Victims of Domestic Elder Abuse 

Child 

47% 

Grandchild 

Parent 

0% 

The largest category of perpetrators (47.3 percent) of the substantiated incidents of elder 

abuse was the adult children of the victims. Spouses represented the second largest group of perpetrators 

comprising 19.3 percent. In addition, other relatives were the third most frequent category of perpetrators 

(8.8 percent), with grandchildren following closely (8.6 percent). 

Figure 4-9. Relationship of perpetrators to victims of domestic abuse 

In-home Service 

r
 provider 

3% 

Out-of home service 

provider 

1% 

Friend/neighbo

6%
 

Other relative
 

9%
 

Spouse 

19% 

Sibling 9% 6% 

When the relationship of perpetrator of domestic elder abuse to victim is examined by type 

of abuse, it is apparent that children are the most likely perpetrators of all types of maltreatment. Neglect 

is the most frequent type of maltreatment, and children accounted for 43.2 percent of the perpetrators. 

Spouses were the next category most likely to neglect victims (30.3 percent). Siblings and grandchildren 

each represented about 9 percent of the perpetrators of neglect. The remainder of the categories of 

perpetrators all represented less than 5 percent of the perpetrators of neglect. 

Perpetrators of emotional/psychological abuse were again most likely to be the children of 

the victim (53.9 percent) followed by the victim's spouse (12.6 percent). Other relatives and 

friends/neighbors were almost equally as likely to be perpetrators of emotional/psychological abuse (11.7 

and 10.3 percent respectively). Grandchildren comprised 8.9 percent of the perpetrators of 

4-28
 
emotional/psychological abuse. The remainder of the perpetrators all represented less than 1 percent. 

Physical abuse was most likely to be committed by adult children (48.6 percent) of the victims of 

domestic elder abuse. The victim's spouse was the next most likely perpetrator of abuse (23.4 percent), 

and friends/neighbors represented one-tenth of the perpetrators of physical abuse (10.2 percent). 

Perpetrators of financial/material exploitation were, again, most likely to be the adult 

children (60.4 percent). The victim's other relative, grandchild, and friends/neighbors were almost 

equally as likely to be perpetrators of financial/material exploitation (9.7 percent, 9.2 percent, and 8.7 

percent respectively). The remainder of perpetrators all represented less than 5 percent of the perpetrators 

of neglect. Perpetrators of abandonment were related to victims of domestic elder abuse in four ways. 

The perpetrators were the adult children (79.5 percent), in-home service providers (7.4 percent), 

grandchildren (6.6 percent), and other relatives (6.4 percent). The confidence bands for estimates of most 

categories of perpetrators (other than children) were too wide to be confident that they are much greater 

than zero, however. Table 4-14 summarizes these findings. 

Table 4-14.	 Relationship of perpetrators to victims of domestic elder abuse for selected types of 

maltreatment1 

Income Emotional/ Financial/
 

Category 

Child 

Neglect Psychological Physical abuse material Abandonment
 

43.2% 53.9% 48.6% 60.4% 79.5%* 

Sibling 8.7%* 1.8%* 4.7%* 1.3%* 0.0% 

Grandchild 8.8%* 8.9%* 5.6%* 9.2%* 6.6%* 

Parent 0.5%* 0.0%* 0.8%* 0.0%* 0.0%* 

Spouse 30.3%* 12.6% 23.4% 4.9%* 6.4%* 

Other relative 3.7%* 11.7%* 5.4%* 9.7%* 0.0%* 

Friend/neighbor 0.6%* 10.3% 10.2% 8.7%* 0.0%* 

In-home service 4.2%* 0.9%* 0.2%* 1.7%* 7.4%* 

provider 

Out-of-home 0.0%* 0.0%* 1.2%* 4.1%* 0.0%* 

service provider 

Percentage of 47.8% 36.1% 26.9% 30.4% 4.2%* 

total perpetrators 

1 Based on an estimated 59,218 substantiated incidents of elder abuse. Some entries have missing values. 

*The confidence band for these numbers is wide, relative to the size of the estimate. The true number may be close to zero or much larger than 

the estimate. 

4-29
 
The nature of caregiving relationships among family members is an important and complex 

issue with regard to the perpetrators of elder abuse and neglect. The NEAIS was not able to explore this 

issue, however, due to the type and scope of data being gathered by the APS workers and sentinels. 

While a broad range of information was collected through interviews and observations, more in-depth 

interviews with both the abused or neglected elders and their family members and caregivers, which are 

necessary to appropriately explore caregiving relationships, were not included in the design of the 

NEAIS. This is certainly an area worthy of a future study that is specifically designed and conducted to 

gather such interview and case study data. 

4.3.2 Characteristics of Self-Neglecting Elders 

Sex of Self-Neglecting Elders 

The data on the substantiated incidents of self-neglect reveal that approximately two-thirds 

of the self-neglecting elders were female, while one-third were male, as shown below in Figure 4-10. 

This is somewhat higher than the 58 percent representation of females in the total elderly population. 

Figure 4-10. Sex of self-neglecting elders* 

Males 

35% 

Females 

65% 

Males, 15,341; females, 28,827 

*Based on an estimated 44,168 substantiated incidents of elder abuse. 

4-30
 
60 to 64 

6% 

Age of Self-Neglecting Elders 

The largest proportions of self-neglecting elders are in the oldest age category (80 and 

older), as the data on the substantiated incidents of self-neglect indicate. As shown in Figure 4-11, 

slightly less than one-half (44.7 percent) of the self-neglecting elders were age 80 and older, compared 

with only six percent who were between 60 and 64 years old. This disparity is strengthened when the 

age breakdown of self-neglecting elders is compared with the age breakdown of the elderly population in 

general. For each of the first three age categories (i.e., 60-64, 65-69, and 70-74), self-neglecting elders 

are under-represented. For example, while 60 to 64 year olds comprise 23 percent of the elderly 

population, they are only 6 percent of self-neglecting elders. This pattern of under-representation changes 

with the 75 to 79 year olds, which make up 16 percent of the elderly population, but are 20 percent of 

self-neglecting elders. The starkest, yet predictable finding was that elders aged 80 or older, who 

comprise 19 percent of the elder population, make-up 45 percent of self-neglecting elders. The older an 

elderly person gets, the more likely it is that she/he will be self-neglecting. 

Figure 4-11. Age of self-neglecting elders* 

65 to 69 

16% 

80 or older 

45% 

70 to 74 

13% 

75 to 79 

20% 

*Based on an estimated 44,168 substantiated incidents of elder abuse. 

4-31
 
Race/Ethnicity of Self-Neglecting Elders 

Figure 4-12 shows that self-neglecting elders fell predominately into three racial/ethnic 

groups. Approximately three-quarters (77.4 percent) of the self-neglecting elders were white. Black selfneglecting elders accounted for 20.9 percent of this population, while American Indians/Alaskan Natives 

and others accounted for 1.7 percent. It should be noted that, because of the large standard errors for this 

variable, the findings presented below should be regarded as tentative. 

Figure 4-12. Race/ethnicity of self-neglecting elders* 

Others** 

Black 2% 

21% 

White 

77% 

*Based on the 44,168 estimated substantiated incidents of elder abuse for which the necessary information was available.
 

**Includes American Indian/Alaskan Native, 1.1%; other/unknown, 0.6%; Hispanic and Asian/Pacific Islander categories were not represented
 

Self Care Ability of Self-Neglecting Elders 

An extremely high proportion (93.4 percent) of elders with substantiated self-neglect has some 

difficulty caring for themselves, with one-third overall not being able to care for themselves. Six out of 

ten were only somewhat able to care for themselves. Only five percent were judged as able to care for 

themselves. These data, shown in Table 4-15, strongly confirm the extremely high, almost totally 

overlapping, relationship between self-neglect and inability to care for one self. 

4-32
 
Table 4-15. Self-Neglecting Elders -- Ability to Care for Self Physically (APS)1 

Characteristics of Maltreated Number of Percentage 

Elders Estimated Reports 

Not Able to Care for Self 14,925 34.3 

Somewhat Able to Care for Self 25,708 59.0 

Able to Care for Self 2,149 4.9* 

Don’t Know, Cannot Determine 762* 1.8* 

1

This table is based on an estimated 43,544 substantiated incidents of self-neglect. Some entries have missing values. 

*The confidence band for these numbers is wide, relative to the size of the estimate. The true number may be close to zero or 

much larger than the estimate. 

Confusion of Self-Neglecting Elders 

Three quarters of substantiated self-neglecting elders suffer from some degree of confusion. 

Three out of ten such elders are very confused or disoriented, while another 45.4 percent are sometimes 

confused. Approximately one quarter (23.6 percent) is not confused and appears to be aware of their 

actions. 

Table 4-16. Self-Neglecting Elders -- Confusion (APS)1 

Characteristics of Maltreated Number of Percentage 

Elders Estimated Reports 

Not Confused 9,815* 23.6 

Sometimes Confused 18,890 45.4 

Very Confused, Disoriented 12,455 29.9 

Don’t Know, Cannot Determine 498* 1.2* 

1

This table is based on an estimated 41,659 substantiated incidents of self-neglect. Some entries have missing values. 

*The confidence band for these numbers is wide, relative to the size of the estimate. The true number may be close to zero or 

much larger than the estimate. 

Depression of Self-Neglecting Elders 

In 28.4 percent of the incidents of substantiated self-neglect, the APS agency was not able to 

determine whether depression was present or not. Over half (53.9 percent) of the self-neglecting elders 

were assessed to not be depressed, while 14.7 percent were judged as moderately depressed. Only a 

relatively small proportion (3.1 percent) was severely depressed. 

4-33
 
4.4 

Table 4-17. Self-Neglecting Elders – Depression (APS) 1 

Characteristics of Maltreated Number of Percentage 

Elders Estimated Reports 

Not Depressed 23,387 53.9 

Moderate Depression 6,366 14.7 

Severe Depression 1,333* 3.1* 

Don’t Know, Cannot Determine 12,335 28.4 

1

This table is based on an estimated 43,421 substantiated incidents of self-neglect. Some entries have missing values. 

*The confidence band for these numbers is wide, relative to the size of the estimate. The true number may be close to zero or 

much larger than the estimate. 

Abuse and Neglect Reported by Sentinel Agencies 

Characteristics of Elderly Victims of Non-Reported Abuse and Neglect 

Overall, sentinels submitted 201 data forms describing incidents they observed during their 

daily work activities. Sentinels were carefully trained to complete forms only for events that met study 

definitions and conformed to specific signs and symptoms. Of these 201 incidents, two different sentinels 

reported four, and 57 were also reported to APS agencies. The duplicate incidents were assigned to APS 

agencies leaving 140 incidents reported only by sentinels. These 140 reports were weighted to provide 

national, annualized estimates of unreported abuse, neglect, and/or self-neglect which extrapolated to 

435,901 new unduplicated incidents during 1996. 

The following tables present data on types of abuse and neglect by age, minority group 

status, gender, and according to physical and mental frailty for incidents reported by the 1,158 sentinels in 

the study counties. Although the weighted numbers estimated from the forms that were collected are 

relatively large, they are based on a small number of actual reports. Consequently, only two or three 

descriptive categories are presented in the tables below. These small numbers also result in large standard 

errors for many values. 

Age. Of the three age categories shown in Table 4-18, the oldest old (those over 80) were 

most likely to suffer from neglect. Sixty percent of the neglected elderly were 80 years or older compared 

to their being 19 percent of the total elderly population (i.e., four times their proportion of the total elderly 

population). Elders aged 80 and over also are over represented in self-neglect and financial exploitation. 

Several forms of abuse and neglect were more commonly experienced by the youngest elderly, aged 60 to 

4-34
 
70. Physical abuse was particularly noteworthy, with 60-70 year olds comprising almost 70 percent 

despite being only approximately 45 percent of the elderly population. This age group is also slightly 

over represented in financial and emotional abuse. Given the large standard errors, however, these 

estimates should be considered tentative. 

Table 4-18. Type of abuse by age: Percentages (Sentinel) 

Type of abuse 

Physical 

60-70 

69.0* 

Age 

71-80 

10.1* 

80+ 

20.1* 

Total 

100% 

Emotional 47.2* 30.2 21.9 100% 

Financial 49.3* 24.3* 25.3* 100% 

Neglect 23.5* 25.6* 60.0 100% 

Abandonment .88* 39.1* 6.0* 100% 

Self-neglect 35.7 28.9* 35.5 100% 

*The confidence band for these numbers is wide, relative to the size of the estimate. The true number may be close to zero or much larger than 

the estimate. 

Race/Ethnicity. The data do not show that rates of unreported abuse and neglect are higher 

in nonminority communities than among minorities. Blacks, Hispanics, and other minorities were 

combined into one category in Table 4-19 (on the next page) because of the small numbers of reports 

received about these groups. Altogether, across the counties in the sample, the Census Bureau classified 

15.5 percent of the population as minority in 1990. Given the relatively high rate of increase in minorities 

throughout the United States since 1990, there is no reason to expect this average percentage to have 

declined substantially in the study counties or, indeed, at all. If minorities were represented 

proportionately in sentinel reports of abuse and neglect, rates of abuse across all categories should be 

close to 15.5. For all five types of abuse and neglect with known perpetrators, the proportion of minority 

victims identified by sentinels ranged between 3.6 and 7.6 percent, whereas the proportion of nonminority 

victims was always greater than 90 percent. Figures for nonminorities have small confidence bands. 

4-35
 
Table 4-19. Type of abuse, by minority status: Percentages (Sentinel) 

Type of Abuse 

Minority status 

Minority Nonminority 

Physical 3.9* 96.1 

Emotional 4.1* 95.9 

Financial 7.6* 92.4 

Neglect 3.6* 96.4 

Abandonment 5.4* 94.6 

Self-neglect 12.1* 88.1 

*The confidence band for these numbers is wide, relative to the size of the estimate. The true number may be close to zero or much larger than 

the estimate. 

Gender. When the data are examined by category of abuse, a majority of victims of all 

types of abuse were women. Over 80 percent of the physical abuse recognized by sentinels, over 90 

percent of the financial abuse, over 70 percent of the emotional/psychological abuse, and over 65 percent 

of neglect cases were found among women rather than men, as shown in Table 4-20. This is a high level 

of over-representation by women, who comprised only 58 percent of the total elderly population in 1996. 

Although rates of abandonment have wide confidence bands, they also show higher proportions of 

women than men do. Cases of self-neglect are more nearly divided exactly as men and women comprised 

the total elderly population. 

Table 4-20. Type of abuse, by gender: Percentages (Sentinel) 

Type of abuse 

Physical 

Gender 

Female 

83.2 

Male 

16.9* 

Total 

100% 

Emotional 72.7 27.3 100% 

Financial 91.8 8.2* 100% 

Neglect 67.2 32.8 100% 

Abandonment 65.4* 34.6* 100% 

Self-neglect 57.0 43.0 100% 

*The confidence band for these numbers is wide, relative to the size of the estimate. The true number may be close to zero or much larger than 

the estimate. 

4-36
 
 

Income. The sentinel data form asked for an estimate of the income of the maltreated elder 

and spouse (if any). Sentinels had sufficient information to make this estimate in only a small number of 

reports, and therefore reliable national estimates could not be made. Sentinels were reporting only initial 

information and observations, as compared with more in-depth information gathered during an APS 

worker’s investigation of abuse or neglect, which allowed APS workers to estimate income 71 percent of 

the time. Sentinels also had less experience than APS reporters did in making income estimates based on 

partial information, for example about Social Security benefits and other complex pension arrangements. 

It is not surprising, therefore, that income estimates from sentinels were not feasible. The economic 

condition of victims of elder abuse and neglect is an important issue and is worthy of future research that 

will specifically gather reliable income and financial resource data. 

Physical and Mental Frailty 

Sentinel reporters were trained to identify the level of depression and confusion of elderly 

victims, where appropriate, as well as their ability to care for themselves. Many professionals in contact 

with elderly clients are accustomed to paying attention to limitations in abilities to perform activities of 

daily living, and to look for signs of confusion and depression. Along any particular dimension of frailty, 

people may not show evidence of symptoms at all times. It may be necessary to observe a person for a 

considerable period of time or to ask specific questions to determine the presence of symptoms. Sentinels 

were asked only to report on what they observed, and not to ask probing questions. They also were asked 

to indicate when they were not able to determine the presence of symptoms by answering “don’t know.” 

Depression is probably the most difficult of the three characteristics to diagnose by 

observation only, since a relatively long term, underlying mood may not be manifested in outward 

behavior. It has been reported that the proportion of elders believed to be depressed ranges from 9.6 to 

12.6 percent.3

 Not surprisingly, approximately a third of the time the sentinels in our study were unable to 

judge whether the person they suspected to be abused seemed depressed. 

3

 Cynthia Thomas, et al., “Depressive Symptoms and Mortality in Elderly People,” Journal of Gerontology, Social Sciences 1992, Vol. 47, 

Number 2, 580-87. 

4-37
 
Self-Care Ability. Sentinels were given three choices of descriptors of an alleged victim’s 

ability to care for himself. Persons could be described as “able to care for self,” “somewhat able to care 

for self,” or “not able to care for self.” Sentinels were unable to make one of these choices 14 percent of 

the time. Half of all persons (51.9 percent) were described either as somewhat able or not able to take 

care of physical needs. Only a third of all persons appeared to be able to take care of themselves (33.8 

percent). See table 4-21. This suggests a high rate of physical frailty among these victims. 

Table 4-21. Ability to Care for Self Physically (Sentinel) 

Characteristics of Number of 

Maltreated Elder 

Estimated Report Percentages 

Not Able To Care For Self 81,981 18.8%* 

Somewhat Able To Care For Self 144,432 33.1% 

Able to Care For Self 147,446 33.8%* 

Don’t Know, Cannot Determine 62,042 14.2%* 

*The confidence band for these numbers is wide, relative to the size of the estimate. The true number may be close to zero 

or much larger than the estimate. 

Confusion. Brief mental impairment tests often are required to assess whether elderly 

people are able to perform mental activities at an appropriate level of competence. Older persons often 

can compensate for minor difficulties, or conceal problems in the early stages of impairment. 

Furthermore, mental impairments may not manifest themselves in all situations. Sentinels were asked to 

look for “confusion” rather than to diagnose an “impairment,” since such a diagnosis would require 

testing. Sentinels were unable to assess whether or not persons were confused for only 18 percent of their 

observations. Nearly half (45.5 percent) of the persons they reported to us were described as “sometimes” 

or “very” confused. Only a third of the time (36.6 percent) did sentinels indicate that no confusion 

appeared to be present. (See Table 4-22 on the next page.) This represents an extremely high rate of 

potential mental impairment among this group of older people. 

4-38
 
Table 4-22. Confusion (Sentinel) 

Characteristics of Number of 

Maltreated Elder Estimated Reports Percentages 

Not Confused 159,498* 36.6% 

Sometimes Confused 165,232 37.9% 

Very Confused, Disoriented 32,777 7.5% 

Don’t Know, Cannot Determine 78,394 18.0% 

*The confidence band for these numbers is wide, relative to the size of the estimate. The true number may be close to zero or 

much larger than the estimate. 

Depression. Sentinels were asked to observe whether the victims they reported to us 

appeared to be experiencing “severe depression,” “moderate depression,” or seemed “not depressed.” As 

noted above, they were unable to determine whether depression was present in a third of the cases they 

saw. Nearly half of the elders (46.9 percent), however, seemed to be depressed to some extent (46.9 

percent). Only 20 percent showed no signs of depression in the presence of the sentinel. See Table 4-23. 

Table 4-23. Depression (Sentinel) 

Characteristics of Number of 

Maltreated Elder Estimated Reports Percentage 

Not Depressed 87,315 20.0% 

Moderate Depression 180,278 41.4% 

Severe Depression 24,036* 5.5%* 

Don’t Know, Cannot Determine 144,273 33.1% 

*The confidence band for these numbers is wide, relative to the size of the estimate. The true number may be close to 

zero or much larger than the estimate. 

Signs of Physical and Mental Frailty for Specific Forms of Abuse and Neglect 

Tables 4-24 through 4-26 present information on self care ability, confusion and depression 

across all six categories of reported abuse and neglect. Because the number of cases in any one category 

is small, resulting in large standard errors, these estimates need to be considered altogether according to 

4-39
 
the patterns they display, rather than by each single measure. The numbers are discussed here according 

to whether there is any apparent indication of frailty, or not, for each type of abuse or neglect. 

Self-Care Ability. Cases of self neglect are often difficult to classify, since, strictly 

speaking, an individual believed to have the physical and mental resources to manage his own personal 

care was not defined by the study as self-neglectful. Persons experiencing neglect, abandonment, and 

self-neglect were most often reported as not able or only somewhat able to take care of themselves. Very 

few of those classified as self-neglecting were reported to be physically independent (11.2 percent). Twothirds of those alleged to have been physically abused were thought to have the ability to care for 

themselves, suggesting that such abuse is not just perpetrated on the very weakest persons. Somewhat 

around half of those facing financial or emotional abuse were considered able to take physical care of 

themselves. Standard errors are large for most categories. See Table 4-24. 

Table 4-24. Ability to Care for Self Physically by Type of Abuse (Sentinel) 

Forms of 

Abuse 

Physical 

Not Able to 

Care For Self 

16.1%* 

Somewhat Able 

To Care For Self 

12.6%* 

Able to Care 

for Self 

67.6%* 

Don’t Know, 

Cannot Determine 

3.8%* 

Emotional 17.8%* 26.3% 40.7%* 15.3%* 

Financial 23.5%* 19.9%* 52.9%* 3.8%* 

Neglect 47.7%* 26.8%* 1.4%* 24.2%* 

Abandonment 64.9%* 35.1%* 0.0% 0.0% 

Self-Neglect 26.2%* 60.2% 11.2%* 2.4%* 

*The confidence band for these numbers is wide, relative to the size of the estimate. The true number may be close to zero or much larger than 

the estimate. 

Confusion. Confusion was most common among those who experienced neglect, 

abandonment, and self-neglect. Very few of those who were abandoned were free from confusion (only 

1.3 percent). Only 7 percent of those reported to have been neglected, and 20 percent of persons who 

were victims of self-neglect evidenced no signs of confusion. Most of those who were reported to have 

been physically abused (66.8 percent) did not appear to be confused. Half of those subjected to financial 

4-40
 
abuse, however, were thought to be confused at least some of the time. Standard errors for most table 

values are large. (See Table 4-25). 

Table 4-25. Confusion by Type of Abuse (Sentinel) 

Forms of Sometimes Very Confused, Don’t Know, 

Abuse Not Confused Confused Disoriented Cannot Determine 

Physical 66.8%* 10.0%* 14.6%* 8.7%*
 

Emotional 43.8%* 34.5%* 3.3%* 18.5%*
 

Financial 51.7%* 33.4%* 11.9%* 3.1%*
 

Neglect 7.1%* 46.8% 21.7%* 24.4%*
 

Abandonment 1.3%* 34.6%* 64.0%* 0.0%
 

Self-Neglect 19.5% 68.8% 2.1%* 9.6%*
 

*The confidence band for these numbers is wide, relative to the size of the estimate. The true number may be close to zero or much larger than 

the estimate. 

Depression. Rates of signs and symptoms of depression were high across all forms of abuse 

and neglect, but standard errors were large for all except two categories. Among those who were 

abandoned, only 1.3 percent was seen as moderately depressed; however, no determination could be made 

as to depression status for nearly two-thirds of them. Except for abandonment, between 35 and 70 

percent of alleged victims of abuse were believed to show signs of moderate or severe depression. In 

only 11 – 35 percent of instances were sentinels able to say that they did not think the victim of abuse was 

depressed. (See Table 4-26). 

Table 4-26. Depression by Type of Abuse (Sentinel) 

Forms of 

Abuse 

Physical 

Not Depressed 

11.1%* 

Moderate 

Depression 

62.9%* 

Severe 

Depression 

0.8%* 

Don’t Know, 

Cannot Determine 

25.2%* 

Emotional 22.7% 46.1%* 7.0%* 24.2%* 

Financial 10.8%* 61.4%* 8.5%* 19.3%* 

Neglect 21.0%* 20.3%* 12.4%* 46.3% 

Abandonment 34.6%* 1.3%* 0.0% 64.0% 

Self-Neglect 18.5%* 52.8% 4.6%* 24.0% 

*The confidence band for these numbers is wide, relative to the size of the estimate. The true number may be close to zero or much larger than 

the estimate. 

4-41 
Characteristics of Perpetrators of Abuse and Neglect Reported by Sentinels 

Approximately 85 percent of incidents of abuse and neglect reported by sentinels had one or 

more alleged perpetrators (10.4 percent had more than one perpetrator). Sentinels were asked to supply 

information about the sex, age, and ethnicity of the person(s) alleged to have committed the abuse, as well 

as the relationship to the victim. Sentinels did not always have complete information about the suspected 

perpetrator. They were most likely to be able to identify the relationship of the person alleged as the 

abuser, which they did for all but .6 percent of the instances, and least likely to report age (10.8 percent), 

according to the weighted numbers. Tables 4-27 and 4-28 present information about the characteristics of 

these alleged perpetrators. Although standard errors are large so that many absolute values of percentages 

are not reliable, the rank order of characteristics is of interest. 

As shown in Table 4-27, family members accounted for most of the suspected perpetrators, 

with spouses (30.3 percent), children (30.8 percent), and parents (24.0 percent) representing 85 percent. 

Although the percentage of alleged parental perpetrators is relatively large, at 24 percent, the confidence 

band is wide, indicating that this estimate is unreliable. Table 4-28 shows that only 29 percent of 

perpetrators with known ages (11 percent of ages are unknown) were at least 60 years old and over. (This 

percentage also has a wide confidence band.) Since parents are likely to be at least 15 years older than 

their children are, these numbers together suggest that very few parents are likely to have perpetrated 

abuse or neglect. 

In small proportions of cases, siblings and grandchildren were involved. Friends, neighbors, 

and service providers in the home were believed to be responsible 10 percent of the time. Data reported 

for most individual categories of people alleged as abusers have large standard errors. Children, however, 

accounted for a significant proportion of alleged abusers, at 30.8 percent. 

4-42
 
Table 4-27. Relationship of alleged perpetrators of abuse 

for sentinel data 

Relationship Percentage 

Child 30.8 

Spouse 30.3* 

Parent 24.0* 

Friend/Neighbor 5.7* 

Grandchild 4.2* 

Service Provider 4.2* 

Sibling .3* 

Not determined .6* 

*The confidence band for these numbers is wide, relative to the size of the estimate. The true number may 

be close to zero or much larger than the estimate. 

The most common age range for perpetrators was the middle years (ages 36 to 59), which 

accounted for 45.4 percent of perpetrators, with close to 30 percent being age 60 and over, and 15 percent 

under age 35, as shown in Table 4-28. Age was not known 10 percent of the time. Nearly twice as many 

were reported perpetrators were men as women (63 percent versus 35 percent). Approximately two-thirds 

of the perpetrators were identified as nonminorities. 

4-43
 
Table 4-28. Characteristics of alleged perpetrators of 

abuse for sentinel data 

Age Percentage 

35 and under 15.3* 

36-59 45.4 

60 and over 28.6* 

Not determined 10.8* 

Sex Percentage 

Male 63.1 

Female 35.4 

Not determined 1.5* 

Ethnicity Percentage 

Minority 36.5*
 

Nonminority 63.5
 

*The confidence band for these numbers is wide, relative to the size of the estimate. 

The true number may be close to zero or much larger than the estimate. 

Sentinel reports represent nearly 80 percent of the total number of incidents, nationwide (and 

would represent an even higher proportion, if the duplicates had been “assigned” to sentinels rather than 

to APS). However, specific characteristics of victims and of perpetrators often have large confidence 

bands due to the relatively small number of events upon which the estimates were based. Nonetheless, 

these results complement and support the data supplied by APS. 

4-44
 
 

 

5. CONCLUSIONS
 

Overview and “Iceberg” Theory 

The results of the National Elder Abuse Incidence Study (NEAIS) confirm the 

validity of the “iceberg” theory of elder abuse that has been accepted in the aging research 

community for 20 years or more. According to this theory, official reporting sources (e.g., Adult 

Protective Services), receive reports about the most visible types of abuse and neglect, but a large 

number of other incidents are unidentified and unreported. Community sentinels, solicited by the 

study for information on their professional encounters with elderly clients and contacts, observed 

such abuse and neglect and learned of incidents that are less obvious and that would not be 

reported to an official agency. 

The best national estimate is that a total of 449,924 elderly persons, aged 60 

and over, experienced abuse and/or neglect in domestic settings in 1996. Of this total, 70,942 

(16 percent) were reported to and substantiated by APS agencies, but the remaining 378,982 (84 

percent) were not reported to APS. From these figures, one can conclude that over five times as 

many new incidents of abuse and neglect were unreported than those that were reported to and 

substantiated by APS agencies in 1996.1 

The best national estimate is that a total of 551,011 elderly persons, aged 60 

and over, experienced abuse, neglect, and/or self-neglect in domestic settings in 1996. Of 

this total, 115,110 (21 percent) were reported to and substantiated by APS agencies, with the 

remaining 435,901 (79 percent) not being reported to APS agencies. One can conclude from 

these figures that almost four times as many new incidents of elder abuse, neglect, and/or selfneglect were unreported than those that were reported to and substantiated by APS agencies in 

1996.2 

1

 The standard error suggests that nationwide as many as 688,948 elders or as few as 210,900 elders could have been victims of abuse
 

and/or neglect in domestic settings in 1996.
 2

 The standard error suggests that nationwide as many as 787,027 elders or as few as 314,995 elders could have been abused,
 

neglected, and/or self-neglecting in domestic settings in 1996.
 

5-1
 
These estimates of the incidence of abuse and neglect (i.e., new incidents) during 

1996 from the NEAIS are lower than other previous estimates. However, it is difficult to 

compare results across these various studies directly because of significant differences in research 

objectives, designs and methodologies. Some studies have examined the prevalence of elder 

abuse (i.e., the total number of cases of abuse in a given population at a designated time), while 

others have explored the incidence (i.e., the number of new cases of abuse occurring over a 

specified period of time). Prevalence studies, by their very definition, produce larger estimates. 

The geographic coverage of studies has differed, with some studies extrapolating to larger areas 

on the basis of selected, but non-random smaller areas. Also, definitions of abuse and neglect and 

research time frames vary considerably across studies, making direct comparison impossible. 

It is also important to acknowledge that there has been a very substantial increase in 

the number of official APS elder abuse and neglect reports over the past ten years. In 1986, a 

total of 117,000 reports (not unduplicated elderly) were received by APS agencies in the states for 

elders age 60 and over. Ten years later in 1996, a total of 293,000 reports (not unduplicated 

elderly) were received by these APS agencies throughout the country for this age group (Tatara 

and Kuzmeskus, 1997). This is an increase of 150 percent over this ten-year period. The elderly 

population, of course, also increased during this time period, and if the rate of reporting to APS 

agencies had simply remained the same the number of reports would have increased just because 

there was a larger elderly cohort that potentially might be abused or neglected. The elderly 

population 60 years old and over did increase by 10 percent between 1986 and 1996, from 38.9 to 

43.9 million. (These numbers are for all elders, including those in institutional settings.) 

Clearly, however, the increase in the total number of elder persons in the country 

explains very little of the phenomenal increase in official APS reporting. Had APS reports 

simply grown in the same proportion as the increase in the size of the elder population itself 

between 1986 and 1996 we could expect 128,700 reports, not 293,000. Even accounting for 

population growth, the number of APS reports increased by 128 percent in these ten years. In 

short, by 1996 a much larger proportion of new incidents of domestic elder abuse and neglect was 

reported to official APS agencies than was reported in 1986. Elder abuse and neglect were not as 

hidden and under-reported to APS as they were earlier. 

This study is the first to attempt to estimate the number of elders abused or 

neglected during a particular year in the United States, whether officially reported to Adult 

5-2
 
Protective Services agencies or unreported and perhaps largely unnoticed or ignored by the 

general population. APS agencies keep data on the total number of cases that they accept for 

investigation each year, but generally they count each report they receive as a separate incident. 

Often, the same event is reported more than once, but these duplicate cases are not removed from 

the counts. Consequently, APS totals overestimate the number of individuals who are reported to 

them as abused or neglected each year. The NEAIS estimates provide data on unduplicated 

numbers of abused, neglected, and self-neglecting elders recognized by these official sources. 

At the same time, as described in the report, most incidents are never reported to 

APS, probably for many different reasons, some of which were mentioned to the field research 

staff during the course of the study. Some NEAIS sentinels claimed they have attempted to 

report cases to APS and, if appropriate actions are not taken, they do not provide additional 

reports. Some of this problem is inherent in the APS process itself because reporters generally 

are not apprised of the outcome of investigations of abuse. Other NEAIS sentinels noted that 

they often encounter situations where elderly persons do not want incidents reported because 

relatives might be implicated who are their only source of support or because they might risk 

abandonment or reprisals. 

Overall, elder abuse is even more difficult to detect than child abuse, since the social 

isolation of some elderly persons may increase both the risk of maltreatment itself and the 

difficulty of identifying that maltreatment. Approximately a quarter of elders live alone, and 

many others interact primarily with family members and see very few outsiders. Children, in 

contrast, never live alone and, furthermore, are required by law to attend school from age 5 until 

16. Consequently, by kindergarten, children come into contact with at least one institution 

outside the home almost daily during much of the year for most of their childhood. Although 

community sentinels are valuable sources of information about abuse and neglect of elders, 

neither they nor other reporting sources can conclusively account for victims of domestic abuse 

and neglect who do not leave their homes and who rarely come in contact with others. 

Consequently, the NEAIS undoubtedly undercounts abuse, neglect, and self-neglect among 

isolated elderly people in domestic settings. 

Figure 5.1 depicts the impact of the NEAIS findings on the “ iceberg” theory of 

elder abuse. The NEAIS data represent the measurement, or mapping, of a large and previously 

unknown segment of the elder abuse iceberg under the water line. A significant, submerged area 

5-3
 
of previously unidentified and unreported elder abuse has been exposed and estimated. NEAIS 

has found that there were over five times as many new incidents of elder abuse and neglect 

previously unidentified and unreported as those that were reported to and substantiated by APS. 

NEAIS researchers also acknowledge that the sentinel methodology (or any methodology) cannot 

identify and report on all hidden domestic abuse and neglect, and that a submerged core of abuse 

and neglect remains unidentified, unreported, and inestimable at this time. The continued 

“mapping” of this final terrain represents a challenge for future research on elder abuse. 

Reported abuse and neglect: 70,942 

estimated new incidents substantiated by 

APS. 

Unreported abuse and neglect: 378,982 

estimated new incidents reported by 

sentinels but not reported to APS. 

Unidentified and unreported new 

incidents 

Figure 5-1.	 Iceberg theory showing NEAIS identified unreported abuse and neglect, 

excluding self-neglect 

Summary of Findings 

Victims of Abuse, Neglect, and Self-Neglect 

Victims reported to APS resemble the characteristics of victims identified by 

sentinel agencies, for many categories of abuse and neglect. Women are disproportionately 

represented as victims, according to reports from both APS and sentinel sources. In APS reports, 

women represent from 60 percent to 76 percent of those subjected to all forms of abuse and 

neglect except abandonment, even though, overall, women represent only 58 percent of the 

elderly population (over 60 years of age). In reports received exclusively from sentinels, from 67 

percent to 92 percent of those reported as abused were women, depending on the type of abuse. 

5-4
 
The greatest disparity between men and women was in reported rates of emotional or 

psychological abuse, according to APS data. Three-fourths of those subjected to this form of 

abuse were women rather than men. According to sentinel reports, the greatest disparity between 

men and women was in the category of financial abuse, in which 92 percent of the victims were 

women. 

A substantial proportion of the victims of neglect was the oldest old (age 80 and 

over), according to both APS and sentinel reports. APS reports showed that 52 percent of neglect 

victims were over age 80. Sentinels found 60 percent in this oldest age range. APS reports also 

suggest that this older category was disproportionately subjected to physical abuse, emotional 

abuse, and financial exploitation. Overall, our oldest elders are abused and neglected at two to 

three times their proportion of the elderly population. 

Sentinel data show that of those subjected to any form of abuse, fewer than 10 

percent were minorities (including Blacks, Hispanics, Asians, Pacific Islanders and others). On 

the other hand, higher proportions of victims of most forms of abuse and neglect reported to APS 

agencies were Black, ranging from 9.percent for physical abuse, the lowest, to 17 percent for 

neglect. Only small proportions of Hispanics and other minorities are represented in most 

categories of abuse reported to APS, generally less than 3 percent altogether. These low 

proportions for these other minorities are supported by the sentinel data. Further research is 

needed to ascertain whether low rates for Hispanics in particular are due to lower rates of 

reporting and detection of abuse and neglect, perhaps because of language barriers, or are due to 

lower rates of actual abuse in these communities. 

Elderly self-neglect also is a serious problem, with about 139,000 new unduplicated 

reports in 1996. (Some of those described as self-neglecting were also subjected to other forms 

of abuse.) Approximately two thirds of self-neglecting elders reported to APS were women. In 

addition, 45 percent of them were over the age of 80. Most victims of self-neglect are unable to 

care for themselves and/or are confused; many are depressed. This is a difficult and troubling 

finding, which warrants attention as well as further research. 

5-5
 
Perpetrators of Abuse and neglect 

Across all categories of abuse and neglect, the distribution of perpetrators by gender 

is almost equal, according to reports received by APS. However, this overall equity is due to the 

preponderance of neglect as a category and the somewhat greater frequency of neglect 

perpetrated by women (52 percent versus 48 percent by men). For all other categories of abuse 

reported to APS, men outnumbered women as perpetrators by at least 3 to 2. Among reports by 

sentinels, which are not broken down by type of abuse because the numbers are too small, male 

perpetrators outnumbered female perpetrators by 1.8 to 1. This preponderance of abuse by men is 

significant both in reports obtained from APS and in sentinel data. 

According to reports received by APS and data supplied by sentinels, most 

perpetrators were younger than their victims. According to information supplied by APS, 65 

percent of total perpetrators were under age 60; close to the same percentage of perpetrators 

identified by sentinels were under age 60. Of course, even perpetrators who are older than 60 

may still be younger than the persons they abuse are. Among reports to APS, the relative “youth” 

of perpetrators of financial abuse is particularly striking compared to other types of abuse, with 

45 percent being 40 or younger and another 40 percent being 41–59 years old. 

Relatives or spouses of the victims commit most domestic elder abuse according to 

reports supplied both by APS and sentinels. Approximately 90 percent of alleged abusers, 

according to both types of sources, were related to victims. APS data suggest that adult children 

are the largest category of abusers, across all forms of abuse, with proportions ranging from 43 

percent for cases of neglect to nearly 80 percent for abandonment, although there were relatively 

few reported instances of abandonment. Adult children also account for the largest category of 

alleged abusers in sentinel reports (39 percent). Since family members are frequently the primary 

caregivers for elderly relatives in domestic settings, this finding that family members are the 

primary perpetrators of elderly abuse is not surprising. 

Limitations of NEAIS Research 

The NEAIS study design had some limitations that prevented it from making an 

estimate of all new incidents of elder abuse and neglect in 1996. First, the sentinel approach 

tends to cause a certain amount of “undercount” in the detection of domestic elder abuse because 

there are no community institutions in which all elders regularly assemble and from which 

5-6
 
sentinels can be chosen and elders observed. In the case of child abuse research, on the other 

hand, schools serve as such a community institution from which primary sentinels are selected. 

The NEAIS was aware of this inherent limitation in the sentinel research design and tried to 

ameliorate this challenge by assigning as many sentinels as appropriate from the four large 

categories of professionals most regularly in contact with elderly people. 

A second and related inherent limitation of the sentinel research design is that 

sentinels cannot observe and report abuse and neglect of elders that are isolated or do not have 

any (or very limited) contact with any community organizations. The sentinel method is most 

effective when well-trained sentinel reporters (which NEAIS’s were) have opportunities to 

observe the same elders over a reasonable period of time. If there is minimal contact between the 

elderly person and sentinels, the opportunities for observing the signs and symptoms of abuse and 

neglect are lessened. 

Finally, limitations in resources available to the NEAIS may have limited the total 

count of elders and the precision of the results. With more resources, it would have been possible 

to sample a larger number of study counties and to follow events in each of them for a longer 

time period. Estimates of child abuse and neglect for the third federally funded incidence study, 

for example, were obtained in 40 primary sampling units (i.e., counties) using more than 3,000 

sentinels over a three-month period, rather than in NEAIS’s 20 sampling units, with 1,200 

sentinels in two months. One of the effects of the smaller number of counties, sentinels, and 

months of reporting was the smaller number of total sentinel reports and the resulting relatively 

large standard errors and wide confidence bands used in calculating the incidence estimates. 

With smaller standard errors, the NEAIS findings could be more definitive, or precise. 

Implications of NEAIS Findings 

The findings of the NEAIS raise a number of important issues for policy 

development, practice, and training in addressing the problems of elder abuse, neglect, and selfneglect. Study findings can provide a basis for designing new and enlightened public policies and 

practices, which are programmatically responsible, fiscally sound, and compassionate. This 

report also presents data to support practitioners, caregivers, social researchers and others in 

identifying new approaches to reduce and prevent abuse, neglect, exploitation, and self-neglect of 

5-7
 
the elderly. Because states and localities historically have had responsibility for elder abuse 

reporting, investigation, intervention, and services, most of the following implications are for 

state and local governments: 

•	 An important target for policy planners is the abuse and neglect among the oldest 

elders, which becomes ever more urgent since those aged 85 and over are the most 

rapidly growing elderly age group. 

•	 Elderly persons who are unable to care for themselves, and/or are mentally confused 

and depressed are especially vulnerable to abuse and neglect as well as self-neglect. 

Perhaps our local community organizations and corporations can be mobilized to 

recognize such potential problems and provide support (e.g., by mobilizing 

neighborhood programs; by educating and sensitizing employees about elder abuse 

and neglect). 

•	 Given the large number of incidents of abuse and neglect that are unidentified and 

unreported, service providers, caregivers, and all citizens who relate to elderly people 

need to be alerted to the problem of abuse and neglect, taught to recognize it, and 

encouraged to report suspected abuse. 

•	 Maintain a comprehensive system of services to respond to reports of elder abuse and 

to provide follow-up services to elder abuse victims. 

•	 Physicians and health care workers may be especially well placed to detect instances 

of abuse, neglect, and self-neglect given that even the most isolated elderly persons 

come in contact with the health care system at some point. The education of 

physicians, nurses, and other health care workers should be focused on how to 

recognize and report signs and symptoms of elder abuse, neglect, and self-neglect 

and where to refer victims for other human and support services. 

•	 Increased standardization of state definitions and general reporting procedures for 

elder abuse and neglect would allow the more meaningful and expedited collection 

and analysis of data about elder abuse, including monitoring national trends in 

incidence over time. 

•	 The Western region of the county reported the largest number of reports to APS of 

any of the regions. With approximately 25 percent of the U.S. population, the 

Western region was the source of 40 percent of the reports. Additionally, almost 60 

percent of the Western region reports were substantiated, in contrast to an overall 

substantiation rate of 49 percent. More detailed study of these Western states may 

provide information on promising policies and practices for identifying and reporting 

abuse that can be replicated elsewhere in the country. 

5-8
 
Future Research Questions and Issues 

The findings of the NEAIS raise a number of questions and issues for researchers 

and service providers to think about in addressing the problems of elder abuse, neglect, and selfneglect. Clearly some of these complex issues will require additional research: 

•	 The confluence of a high proportion of adult children, spouses, and particularly parents being 

perpetrators, along with the high proportion of perpetrators being 80 and over, suggests that 

the following may be important areas for further study: 

�

�

�

the relationship between abusive family members and caregiving responsibilities; 

the relationship between abusive spouses and parents and their caregiving 

responsibilities, particularly for neglect; and 

the relationship between 80+ year old perpetrators and caregiving responsibilities. 

•	 Are there characteristics of the perpetrators, aged 60 and over, that aging service providers 

could affect by reaching out and providing services so that abuse committed by perpetrators 

aged 60+ is reduced? 

•	 Are there characteristics of the caregiving relationships among younger family members who 

financially exploit their older relatives that could be affected by service interventions for the 

perpetrators? What are those interventions? Are there services or education for persons aged 

60+ that would help them from becoming victims of financial abuse, particularly by younger 

family members? 

•	 What is the economic condition of victims of abuse and neglect compared with elders 

overall? 

•	 In-home service providers reported all substantiated sexual abuse cases. Why is this so? 

What do they know/see that other reporters do not? How can we capitalize on their 

knowledge? 

•	 Why are black elders more likely to be self-neglecters (18 percent of the substantiated APS 

reports compared to being 8 percent of the elder population)? 

•	 Why do sentinels recognize abuse among women at a much higher rate than is reflected 

among APS reports? Do we need to train people better to recognize and detect abuse among 

men? 

•	 Why do sentinels not see more self-neglect cases than are reported to APS agencies, as 

sentinels do for abuse and neglect? 

•	 How can employees of banks be educated and encouraged to identify and report incidents of 

financial exploitation that may come to their attention while serving elderly customers? 

Although the NEAIS was not very successful in obtaining reports from bank sentinels, banks 

are in a good position to observe financial abuse and concerted attention should be given to 

how to better involve them in future research on elder abuse incidence. States and 

communities with particularly strong bank reporting of financial exploitation (e.g., 

Massachusetts and San Diego) may provide promising practices for such larger replication. 

5-9
 
Conclusion 

In conclusion, the NEAIS has documented the existence of a previously unidentified 

and unreported stratum of elder abuse and neglect, thus confirming and advancing our 

understanding of the “iceberg” theory of elder abuse. NEAIS estimates that for every abused and 

neglected elder reported to and substantiated by APS, there are over five additional abused and 

neglected elders that are not reported. NEAIS also acknowledges that it did not measure all 

unreported abuse and neglect. Our collective challenge — as policy makers, service providers, 

advocates, researchers, and society as a whole, is to utilize this information to better the lives of 

our elder citizens. 

5-10
 
5-11
 
REFERENCES
 

Block, M.R. and Sinnott, J.D. (Eds.) (1979). The battered elder syndrome: An exploratory study. College 

Park, Maryland: University of Maryland Center on Aging. 

Dolon, R. and Blakely, B. (1989). "Elder abuse and neglect: A study of adult protective service workers 

in the United States. Journal of elder abuse and neglect, I, 31-49. 

Douglas, R.L., Hickey, T., and Noel, C. (1980). A study of maltreatment of the elderly and other 

vulnerable adults. Ann Arbor, Michigan: University of Michigan Institute of Gerontology. 

Gioglio, G.R. and Blakemore, P. (1982). Elder abuse in New Jersey: The knowledge and experience of 

abuse among older New Jerseyans. Trenton, New Jersey: New Jersey Department of Human 

Resources. 

Lau, E. and Kosberg, J.I. (1979). Abuse of the elderly by informal care providers. Aging 

(September/October), 11-15. 

Lehtonen, R., and Pahkinen, E.J. (1996). Practal Methods for Design and Analysis of Complex Survey, 

Revsided edition. Chichester: Wiley. 

O'Malley, H., Segars, H., Perez, R., Mitchell, V., and Knuepfel, G. (1979). Elder abuse in 

Massachusetts: A survey of professionals and paraprofessionals. Boston, Massachusetts: Legal 

Research and Service for the Elderly. 

Pillemer, K. and Finkelhor, D. (1988). The prevalence of elder abuse: a random sample survey. The 

Gerontologist, 28, 51-57. 

Sengstock, M.C. and Liang, J. (1982). Identifying and characterizing elder abuse. Detroit, Michigan: 

Wayne State University Institute of Gerontology. 

Steinmetz, S.K. (1981). Elder abuse. Aging (January-February), 6-10. 

Tatara, T. (1989). Toward development of estimates of the national incidence of elder abuse based on 

currently available data: An exploratory study. In Filison and Ingram (Eds.), Elder abuse: 

Practice and policy, 153-165. New York: Human Services Press. 

Tatara, T. (1990). NARCEA's suggested state guidelines for gathering and reporting domestic elder 

abuse statistics for compiling national data. Washington, DC: NARCEA. 

Tatara, T. (1990). Summaries of national elder abuse data: An exploratory study of state statistics. 

Washington, DC: NARCEA. 

Tatara, T. (1993). Summaries of the statistical data on elder abuse in domestic settings for FY 90 and FY 

91. Washington, DC: NARCEA. 

Tatara, Toshio (1995). An analysis of state laws addressing elder abuse, neglect, and exploitation. 

Washington, DC: NCEA. 
Tatara, T. and Blumerman, L. (1996). Summaries of the statistical data on elder abuse in domestic 

settings: An exploratory study of state statistics for FY 93 and FY 94. Washington, DC: NCEA. 

Tatara, T. and Kuzmeskus, L. (1997). Summaries of the statistical data on elder abuse in domestic 

settings: An exploratory study of staff statistics for FY 95 and 96. Washington, DC: NCEA. 

Thomas, Cynthia et al., “Depressive Symptoms and Mortality in Elderly People,” Journal of Gerontology, 

Social Sciences 1992, Vol 47, Number 2, 580-87 

U.S. House of Representatives, Subcommittee on Health and Long Term Care, Select Committee on 

Aging. (1981). Elder abuse: An examination of a hidden problem (Publication No. 97-277). 

Washington, DC: U.S. Government Printing Office. 

Wolter, K.M. (1985). Introduction to Variance Estimatation. New York: Springer-Verlag