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Article

Prevalence of Elder Polyvictimization in the United States: Data From the National Elder Mistreatment Study

Joah L. Williams, PhD,1 Elise H. Racette, MA,1 Melba A. Hernandez-Tejada, DHA,2 and Ron Acierno, PhD2,3

Abstract Elder abuse, including emotional, physical, sexual, financial, and neglectful mistreatment is widespread in the United States, with as much as 11% of community-residing older adults experiencing some form of abuse in the past year. Little data exist regarding the prevalence of polyvictimization, or experience of multiple forms of abuse, which may exacerbate negative outcomes over that of any one form of victimization in isolation. This study evaluates the prevalence of elder polyvictimization among a nationally representative sample of community-residing U.S. older adults. Data from the National Elder Mistreatment Study were examined using bivariate and logistic regression analyses. Approximately, 1.7% of older adults experienced past-year polyvictimization, for which risk factors included problems accomplishing activities of daily living (odds ratio [OR] = 2.47), low social support (OR = 1.64), and past experience of traumatic events (OR = 4.81).

1University of Missouri–Kansas City, USA 2Medical University of South Carolina, Charleston, USA 3Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA

Corresponding Author: Joah L. Williams, Department of Psychology, University of Missouri–Kansas City, 5030 Cherry St., Rm. 310, Kansas City, MO 64110, USA. Email: williamsjoah@umkc.edu

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4518 Journal of Interpersonal Violence 35(21-22)

Elder polyvictimization is a serious problem affecting community-residing older adults with identifiable targets for intervention.

Keywords elder abuse, adult victims, sexual assault, domestic violence

Elder abuse and mistreatment are widespread problems in the United States, with as much as 11% of community-residing older adults aged 60 years or older experiencing some form of abuse in the past year (Acierno et al., 2010). Most widely accepted definitions of elder abuse include five categories of mistreatment: emotional/verbal abuse, physical abuse, sexual abuse, finan- cial exploitation, and neglect (Centers for Disease Control and Prevention, 2016). Such abusive acts against older adults are associated with a number of serious mental and physical health problems, including depression, anxiety, fractures, malnutrition, and early mortality (e.g., Dong, 2005; Dong, Beck, & Simon, 2010; Dong et al., 2009; Dyer, Pavlik, Murphy, & Hyman, 2000). Although the full economic impact of these injuries is unknown, estimates for these multiple forms of elder abuse (e.g., physical, financial, psychologi- cal, sexual, neglect, etc.) have been reported to cost Americans well over US$10 billion dollars annually (White House Conference on Aging, 2005), with financial abuse adding another US$2.9 billion to the cost (MetLife Mature Market Institute, 2011).

There is evidence that many victims of elder mistreatment will experience multiple forms of abuse, or polyvictimization. Ramsey-Klawsnik and Heisler (2014) define elder polyvictimization as

multiple co-occurring or sequential types of elder abuse by one or more perpetrators, or when an older adult experiences one type of abuse perpetrated by multiple others with whom the older adult has a personal, professional, or care recipient relationship in which there is a societal expectation of trust. (p. 15)

Similarly, the U.S. Department of Justice (2015) defines elder polyvictimiza- tion as the co-occurrence of multiple forms of abuse. An important area of overlap worth noting here is that both definitions of elder polyvictimization involve the co-occurrence of multiple forms of abuse. Thus, for the purposes of this study, we define elder polyvictimization as the co-occurrence of dif- ferent forms of abuse and mistreatment.

Conceptually, the polyvictimization framework has the potential to facili- tate major advances in the study of elder abuse. That is, examining single types of victimization in isolation may fail to capture the complexity of

Williams et al. 4519

victimization experiences for many older adults and lead clinicians and/or researchers to inappropriately attribute distress and functional impairment to a single type of victimization rather than the cumulative burden of victimiza- tion (Hamby, Smith, Mitchell, & Turner, 2016). Indeed, polyvictimation may well increase risk for a number of poor physical and mental health-related outcomes above and beyond experiencing any single type of victimization. For example, in a sample of 54 confirmed cases of elder mistreatment reported to an Adult Protective Services agency in Virginia, older adult vic- tims of hybrid financial exploitation, or financial exploitation that co-occurred with physical abuse and/or neglect, were less likely to be healthy and more likely to fear their abusers than older adults experiencing financial exploita- tion in isolation (Jackson & Hafemeister, 2012). Moreover, the magnitude of financial loss was substantially higher for those victims of hybrid financial exploitation (victims of hybrid financial exploitation lost on average US$185,574 vs. US$79,422 among victims of financial exploitation without other co-occurring forms of victimization), highlighting the need to better understand risk factors for elder polyvictimization.

Indeed, only a few studies have explored rates of elder polyvictimization among community-residing older adults, and these rates vary substantially by region and other sociocultural factors. For example, in a sample of 1,017 randomly selected elders aged 65 to 101 years who were enrolled in the Iowa Medicaid Waiver Program, 15.8% reported experiencing one type of abuse, 4.0% reported experiencing two types of abuse, and 1.0% reported experi- encing three types of abuse (Buri, Daly, Hartz, & Jogerst, 2006). In another study involving 129 people with dementia and their caregivers (Wiglesworth et al., 2010), researchers found that 47.3% of these older adults had been abused in the past year; of this group, 31% experienced multiple types of mistreatment (of note, all of the adults who were physically abused in the past year in the sample also experienced psychological abuse, neglect, or both). More recently, high rates of polyvictimization were observed in a sample of Latino older adults aged 66 years and older in low-income, minority areas in Los Angeles, such that an astonishing 21% of these older adults had experi- enced multiple forms of abuse in the past year (DeLiema, Gassoumis, Homeier, & Wilber, 2012). It is not clear, though, that these prevalence esti- mates are representative of the general population of older adults in the United States, given that no studies to date have looked at rates of elder poly- victimization among a nationally representative sample of U.S. older adults.

Abroad, studies have also yielded variable prevalence estimates of elder polyvictimization in the community, and, importantly, some of these interna- tional efforts have included estimates derived from nationally representative data. In a community-based sample of Dutch older adults in Amsterdam, for

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example, approximately 0.4% of older adults had experienced two or more types of abuse in the past year (Comijs, Pot, Smit, Bouter, & Jonker, 1998). Researchers in Spain noted higher rates of polyvictimization in their sample of 676 community-dwelling Spanish older adults, with 3.6% of the sample reporting two or more types of abuse in the past year and 0.1% of the sample endorsing three or more types of abuse in the past year (Garre-Olmo et al., 2009). Results from a national prevalence study in Portugal revealed a simi- lar polyvictimization rate of 3.4% among Portuguese older adults (Gil et al., 2015). Further illustrating the considerable variability in international preva- lence estimates, an examination of elder abuse prevalence among older adults in rural communities in Hubei, China, revealed that approximately 10.5% of these older adults had experienced two or more types of mistreatment in the past year (Wu et al., 2012).

Thus, it seems clear that elder polyvictimization may be more prevalent in the community than previously thought, underscoring the need to identify key risk factors for polyvictimization. Some known risk factors for elder abuse identified by prior research include (but are not limited to) gender, socioeconomic status, race/ethnicity, prior trauma exposure, and low social support (Acierno et al., 2010; Biggs, Manthorpe, Tinker, Doyle, & Erens, 2009; Hernandez-Tejada, Amstadter, Muzzy, & Acierno, 2013; Laumann, Leitsch, & Waite, 2008). No studies, however, have explored whether these characteristics can distinguish polyvictims from older adults who experience single types of victimization in isolation. Thus, the two primary aims of this study are to (a) evaluate the prevalence and correlates of elder polyvictimiza- tion using data from the National Elder Mistreatment Study—a nationally representative survey of elder abuse and neglect among community-residing U.S. adults aged 60 years and older, and (b) identify demographic risk factors for polyvictimization among this sample of older adults.

Method

Participants

Participants for this study were 5,776 adults (weighted sample; 5,777 older adults in unweighted sample) aged 60 years or older, recruited as part of the National Elder Mistreatment Study (Acierno et al., 2010). The sample was selected using stratified random-digit dialing in an area probability sample derived from Census-defined size-of-place parameters (e.g., rural, urban) in the continental United States. Interviews were conducted in either English or Spanish depending on participant preference using standardized computer Helped telephone interviewing procedures. The cooperation rate was 69%.

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Study procedures are described in full detail in a prior publication from this data set (see Acierno et al., 2010), and the research protocol was reviewed and approved by the Medical University of South Carolina’s institutional review board.

The final sample consisted of 2,300 (39.8%) males and 3,477 (60.2%) females with a mean age of 71.46 years (SD = 8.08). In terms of racial/ethnic identity, 4,876 (84.4%) adults identified as Caucasian, 386 (6.7%) African American, 245 (4.3%) Hispanic, 132 (2.3%) American Indian or Alaskan Native, 49 (0.9%) Asian, and 13 (0.2%) Pacific Islanders. The majority of participants were retired or unemployed (5,174; 80.9%), and just over half of the sample reported that they were married or cohabitating (3,281; 56.8%). Approximately, one third of participants (2,176; 37.8%) reported needing some Helpance with activities of daily living (ADL).

Measures

Demographics. Demographic variables, including age, gender, education level, ethnicity, and race, were assessed as part of the interview. Ethnicity was assessed via a single question: “Are you of Hispanic origin or descent?” Race was assessed via the following question: “In which of the following categories do you feel you belong: White, Black, Pacific Islander, American Indian or Alaskan Native, Asian, or something else?” Participants were also asked about household income, and, for purposes of this study, low income was defined as cases where the combined household income was less than US$35,000 per year. Marital and relationship status was assessed with the question, “What is your marital status?”

Elder abuse. A series of behaviorally specific questions regarding emotional, physical, and sexual abuse, neglect, and financial mistreatment were used to assess past-year elder abuse in survey form as validated by Acierno, Resnick, Kilpatrick, and Stark-Riemer (2003). These questions were worded so as to elicit a “yes” or “no” response rather than a description of specific mistreat- ment events to increase participant privacy and protection. After Question Assignmenting about the specific abuse type, respondents were asked how long ago the abuse happened (i.e., “How old were you when this happened most recently?”) to establish past-year prevalence. Here, emotional abuse was defined as an affirmative response to any one of the following four questions: (a) “Has anyone ever verbally attacked, scolded, or yelled at you so that you felt afraid for your safety, threatened, or intimidated?” (b) “Has anyone ever made you feel humiliated or embarrassed by calling you names such as stupid, or telling you that you or your opinion was worthless?” (c) “Has anyone ever forcefully

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or repeatedly asked you to do something so much that you felt harassed or coerced into doing something against your will?” (d) “Has anyone close to you ever completely refused to talk to you or ignored you for days at a time, even when you wanted to talk to them?”

Physical abuse was defined as an affirmative response to any one of the following three questions: (a) “Has anyone ever hit you with his or her hand or object, slapped you, or threatened you with a weapon?” (b) “Has anyone ever tried to restrain you by holding you down, tying you up, or locking you in your room or house?” (c) “Has anyone ever physically hurt you so that you suffered some degree of injury, including cuts, bruises, or other marks?”

Sexual abuse was defined as an affirmative response to any one of the fol- lowing three questions: (1) “Regardless of how long ago it happened or who made the advances, has anyone ever made you have sex or oral sex by using force or threatening to harm you or someone close to you?” (2a) For females: “Has anyone ever touched your breasts or pubic area or made you touch his penis by using force or threat of force?” (2b) For males: “Has anyone ever touched your pubic area or made you touch their pubic area by using force or threat of force?” (3a) For females: “Has anyone ever forced you to undress or expose your breasts or pubic area when you didn’t want to?” (3b) For males: “Has anyone ever forced you to undress or expose your pubic area when you didn’t want to?”

Potential neglect was defined as an affirmative response to one of the fol- lowing six questions regarding personal need, along with a response indicat- ing that there was no one available to fulfill that need: (a) “Do you need someone to help you get to the places you need to go, for example, do you need someone to drive you to the grocery store, a place of worship, the doc- tor?” (b) “Do you need someone to make sure you have enough food, medi- cines, or any other things you need in your house?”(c) “Do you need someone to help you with household things, like cooking meals, helping you eat, or making sure you take the correct medicines each day?”(d) “Do you need someone to help you with house cleaning or yard work?” (e) “Do you need someone to help you get out of bed, get showered, or get dressed?” (f) “Do you need someone to make sure your bills get paid?”

If the older adult acknowledged that someone helps him or her manage his or her finances, or someone other than the elder makes decisions about his or her money and property, financial exploitation was defined as an affirmative response to one of the following questions with reference to that individual: (a) “Does that person ask for your PERMISSION before deciding to spend your money or sell your property?” (b) “Do you feel like that person makes good decisions about your finances?” (c) “Do you have the copies of paperwork for the financial decisions they make or can you get copies if you wanted them?”

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(d) “Has that person ever forged your signature without your permission to sell your property or to get money from your accounts?” (e) “Has that person ever forced or tricked you into signing a document so that he or she would be able to get some of your money or possessions?” (f) “Has that person, or anyone else you are close to, ever stolen your money or taken your things for them- selves, their friends, or to sell?” (g) “Has a stranger ever spent your money or sold your property without your permission?” (h) “Has a stranger ever forged your signature to get some of your money or sell your property?” (i) “Has a stranger ever forced or tricked you into signing a document so that he or she would be able to get some of your money or possessions?” For purposes of this study, we only assessed financial exploitation perpetrated by a family member, and, thus, financial exploitation by a stranger was not included in our definition of financial exploitation. Perpetrator characteristics by type of abuse are pro- vided in prior publications from this data set (Amstadter et al., 2011).

Health status. Health status over the prior month was assessed using the gen- eral health Question 1 from the World Health Organization Short-Form 36 Health Questionnaire (Ware & Gandek, 1998). Participants were asked to rate the following question: “In general, would you say your health is excel- lent, very good, good, fair, or poor?”

Prior traumatic events. Participants were asked to report if they had been exposed to the following events and indicated fear that they would be killed or seriously injured during this exposure: natural disasters such as earth- quake, hurricane, flood, or tornado; serious accident at work, in a car, or somewhere else; or being in any other situation where you thought you would be killed.

Social support. Perceived social support during the past month was assessed via a modified five-item version of the Medical Outcomes Study module for social support (Sherbourne & Stewart, 1991). Participants were asked about emo- tional (e.g., “someone available to love you and make you feel wanted”), instrumental (e.g., “someone available to help you if you were confined to bed”), and appraisal (e.g., “someone available to give you good advice in a crisis”) social support and responded to items using a 4-point scale from none of the time to all of the time. Low social support was operationalized as a score in the lower quartile of the sample ratings, and the comparison high social sup- port was operationalized as a score in the upper quartile of sample ratings.

Social service utilization. Participants were asked if they had used any of the following programs or services: senior centers or day programs; physical

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rehabilitation; Meals on Wheels or any other meal service, social services or health services provided to the home; hospice; formal senior friends services, church group home visits, or any other program or service. Participants responded to these questions using dichotomous “yes” or “no” responses.

ADL Helpance. Participants were asked if they needed help from time to time with the following ADLs: shopping for groceries or medicines; going to the doctor; transportation to friends, church, or temple; paying bills or doing related paperwork; taking medicines, getting dressed, bathing, and eating. Participants responded to these questions using dichotomous “yes” or “no” responses.

Data Analysis Plan

Frequency distributions were computed to assess the prevalence of polyvic- timization, here defined as having experienced two or more categories of mistreatment (emotional, physical, sexual, and financial abuse and neglect) in the past year. Bivariate analyses comparing older adults with no past-year abuse, older adults reporting one form of victimization, and elder polyvictims on various demographic factors were conducted using a series of χ2 analyses. Analyses were also conducted just comparing older adults reporting one form of victimization and elder polyvictims. For comparisons, racial groups were collapsed into a dichotomous variable (White and non-White) given the small number of individuals in several racial categories screening positive for poly- victimization, and, in looking at marital/relationship status, participants were categorized as married or cohabitating or not in a long-term relationship (e.g., separated, divorced, widowed, single). Consistent with prior publications from this data set (e.g., Acierno et al., 2010), we also collapsed age into a dichotomous variable representing young-old (aged 60-69 years) and old-old (aged ≥ 70 years). A significance level of p < .05 was chosen a priori. A logis- tic regression analysis was conducted to explore the unique contribution of demographic risk factors to endorsement of polyvictimization. For all of the following analyses, data were weighted based on age and sex to match 2000 Census estimates, and, thus, all ns and proportions reported in the results are based on weighted data unless otherwise specified. Analyses were conducted using SPSS Version 23 software.

We examined each abuse and mistreatment variable for missing data, and rates of missingness were generally low, ranging from 0.3% to 7.1% for the emotional abuse, physical abuse, sexual abuse, and neglect variables. Only one abuse variable, financial exploitation, had a missing data rate >10% (13.1%). Missing data were handled such that rates of victimization,

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including polyvictimization, were computed based on the number of abuse variables with valid data. For our primary analyses, cases were excluded analysis by analysis with tests using all cases with valid data for each tested variable. Listwise deletion was used for logistic regression analyses.

Results

In the past year, and including financial exploitation in overall estimates, 12.4% (n = 715) of the sample reported experiencing one form of elder abuse, and 1.7% reported having experienced more than one form of abuse (i.e., polyvictimization; n = 101). More specifically, 1.5% (n = 85) reported two types of abuse, 0.2% (n = 14) reported three, and <1% (n = 2) reported four types of abuse in the past year. Among elder polyvictims, the most commonly endorsed forms of abuse were emotional abuse (72.3%, n = 71), neglect (57.6%, n = 58), and physical abuse (43.7%, n = 42). Lower rates of financial exploitation (39.0%, n = 37) and sexual abuse (13.9%, n = 12) were observed among this sample of elder polyvictims (see Table 1). By comparison, the most commonly endorsed categories of abuse among nonpolyvictims who reported some form of abuse in the past year were financial exploitation (34.5%, n = 227), neglect (33.5%, n = 239), and emotional abuse (27.2%, n = 183). Past-year prevalence of physical and sexual abuse among nonpolyvic- tims endorsing some form of abuse in the past year was 7.0% (n = 44) and 3.3% (n = 22), respectively. Elder polyvictims were more likely than non- polyvictims to experience every category of abuse except financial exploitation.

Among elder polyvictims, emotional abuse was the most common type of abuse co-occurring with other abuse categories such that 80% of polyvictims reporting past-year physical abuse, 66.7% reporting past-year sexual abuse,

Table 1. Rates of Endorsement of Abuse Categories Among Elder Polyvictims and Elders With a Past-Year History of a Single Category of Victimization.

Variable Single Victims

n (%) Polyvictims

n (%) χ2 OR 95% CI

Emotional abuse 183 (27.1) 71 (72.4) 79.73*** 0.14 [0.09, 0.23] Physical abuse 44 (6.9) 42 (43.8) 108.92*** 0.10 [0.06, 0.16] Sexual abuse 22 (3.4) 12 (13.8) 19.17*** 0.22 [0.10, 0.46] Neglect 239 (33.5) 58 (57.4) 21.82*** 0.37 [0.25, 0.57] Financial exploitation 227 (34.5) 37 (38.9) 0.72 0.83 [0.53, 1.29]

Note. OR = odds ratio; CI = confidence interval. *p < .05. **p < .01. ***p < .001.

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Table 2. Demographic Comparisons of Elder Polyvictims and Elders With a Past- Year History of a Single Category of Victimization.

Variable

No Victimization

n (%) Single Victims

n (%) Polyvictims

n (%) χ2

Needs help ADL 1,640 (33.2) 453 (63.5) 82 (82.0) 329.04*** Prior traumatic event 2,974 (60.2) 498 (70.1) 94 (93.1) 67.875*** Lower social support 1,077 (24.2) 255 (39.9) 47 (55.3) 106.830*** Poor health 974 (19.8) 256 (36.1) 50 (50.0) 140.520*** Racial minority 458 (9.7) 99 (15.1) 24 (24.5) 37.302*** Unemployed 3,898 (80.9) 555 (80.8) 84 (85.7) 1.460 Old-old age (>70) 2,481 (50.9) 313 (44.7) 38 (37.6) 15.619*** Lower income 1,655 (44.3) 297 (56.8) 50 (65.8) 40.966*** Use of social services 1,945 (39.7) 333 (47.4) 51 (50.5) 18.885*** Female 2,977 (60.0) 436 (61.0) 64 (63.4) 0.680 Education equal to or

less than HS diploma 2,002 (41.3) 307 (44.6) 43 (44.3) 2.964

Married/living together 2,866 (58.4) 369 (52.3) 46 (45.5) 15.591*** Hispanic ethnicity 107 (2.2) 25 (3.7) 1 (1.0) 6.151*

Note. Reference categories for variables were as follows: Needs help ADL = perform ADLs independently; prior traumatic event = no history of prior traumatic events; low social support = individuals indicating high social support; poor health = reporting good health; racial minority = White; Hispanic ethnicity = non-Hispanic. ADL = activities of daily living; HS = high school. *p < .05. **p < .01. ***p < .001.

and 52.7% reporting past-year neglect also reported past-year emotional abuse. Neglect, however, was the most commonly endorsed form of co- occurring abuse among polyvictims with a past-year history of financial exploitation, with 51.4% of financially exploited polyvictims also reporting recent neglect. Of the two older adults reporting four types of abuse in the past year, one reported being emotionally, physically, and sexually abused and financially exploited in the past year. The other older adult reporting four types of abuse reported being emotionally, physically, and sexually abused and neglected in the past year.

To examine mistreatment risk in relation to demographic variables, health ratings, social support, social services use, and exposure to prior traumatic events, a series of χ2 analyses were conducted comparing older adults with no past-year victimization, those reporting one form of victimization, and elder polyvictims. Results are presented in Table 2. Compared with their nonvic- timized peers and older adults who experienced a single form of victimiza- tion in the past year, a greater proportion of elder polyvictims reported

Williams et al. 4527

needing ADL Helpance (82.0%, n = 82), having experienced a prior trau- matic event (93.1%, n = 94), lower social support (55.3%, n = 47), poor health (50.0%, n = 50), identifying as a racial minority (24.5%, n = 24), hav- ing lower overall income (65.8%, n = 50), and using social services (51.5%, n = 51).

To more specifically explore the question of polyvictimization risk in rela- tion to these variables of interest, we ran the same set of analyses comparing elder polyvictims with the subset of older adults who endorsed a single type of mistreatment in the past year. Compared with older adults who experienced one type of victimization in the past year, polyvictims were more likely to report needing help with ADLs, χ2(1, N = 813) = 13.30, p < .001, have previously experienced a potentially traumatic event, χ2(1, N = 811) = 23.58, p < .001, and report lower social support, χ2(1, N = 724) = 7.31, p = .007. Polyvictims were also more likely to endorse poor health, χ2(1, N = 809) = 7.19, p = .007, and identify as a racial minority, χ2(1, N = 755) = 5.55, p = .018.

To explore the unique contribution of each factor to reported polyvictim- ization, we conducted a logistic regression analysis with demographic factors simultaneously entered as independent variables. A variable representing past-year poly- versus single victimization was entered as the dependent vari- able. Only those variables that reached statistical significance in bivariate analyses comparing polyvictims and single victims were entered as predic- tors in the final model. Results are presented in Table 3. Risk of polyvictim- ization was greater among older adults needing help with ADLs (OR = 2.47), those with low social support (OR = 1.64), and those who had experienced a prior traumatic event (OR = 4.81).

Table 3. Logistic Regression Analysis With Demographic Factors Predicting Past- Year Polyvictimization.

Variable B SE p OR 95% CI

Constant −4.273 0.49 .000 0.01 Racial minority 0.46 0.29 .112 1.59 [0.90, 2.81] Low social support 0.49 0.25 .049 1.64 [1.00, 2.67] Prior traumatic event 1.57 0.42 .000 4.81 [2.12, 10.92] Poor health 0.07 0.26 .803 1.07 [0.64, 1.79] Needs help ADL 0.90 0.32 .005 2.47 [1.32, 4.62]

Note. Reference categories for variables were as follows: Racial minority = White; low social support = individuals indicating high social support; prior traumatic event = no history of prior traumatic events; poor health = reporting good health; needs help ADL = perform ADLs independently. OR = odds ratio; CI = confidence interval; ADL = activities of daily living.

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Discussion

To our knowledge, this is among the first studies to examine the prevalence of elder polyvictimization in a nationally representative sample of commu- nity-residing older adults in the United States. Our data suggest that nearly 2% of community-residing older adults will experience multiple forms of abuse each year. This equates to over 970,000 older adults in the United States (based on 2010 U.S. Census estimates for ages 60 and older). Although a relatively small proportion of the older adult population overall, these elder polyvictims are more likely to experience virtually every category of elder mistreatment other than financial exploitation compared with victims of sin- gle types of mistreatment, underscoring the need for more targeted screening and intervention efforts for those adults most vulnerable to abuse and mistreatment.

The elder polyvictimization rate of 1.7% observed in our community- residing sample is higher than that observed in a community-residing sample of Dutch older adults (Comijs et al., 1998) but less than rates observed in epidemiological samples of older adults in Spain and Portugal (Garre-Olmo et al., 2009; Gil et al., 2015). Although these different prevalence estimates could reflect cultural differences in elder abuse prevalence, they more likely underscore the fact that definitional issues confound the accurate collection of elder abuse rates across cultures. Indeed, there are no expert consensus definitions for various categories of mistreatment, which limits the ability to compare findings across studies both across and within cultures (Roberto, 2016). For example, Comijs and colleagues used frequency criteria in deter- mining “caseness” of emotional abuse and neglect in their sample of Dutch elders, defining cases of emotional abuse and neglect as those where 10 or more episodes of abuse had occurred during the past year. Of note, these researchers did not assess for sexual abuse, which could have led to lower prevalence estimates. In both the current study and in Garre-Olmo and col- leagues’ study of Spanish older adults, caseness of abuse and neglect were determined on the basis of a positive response to any of the questions for each abuse category. Because such different assessment strategies are adopted across studies, establishing standardized definitions of abuse categories and standardized screening procedures is a crucial next step for elder abuse research.

As important as it is to establish standardized definitions of various abuse categories, it is just as important to establish a standardized definition of elder polyvictimization. Whereas most definitions include the co-occurrence of mul- tiple types of abuse (e.g., Ramsey-Klawsnik, & Heisler, 2014; U.S. Department of Justice, 2015), some definitions consider repeatedly experiencing a single

Williams et al. 4529

type of abuse to be polyvictimization. Other researchers (e.g., Hamby et al., 2016) have argued that a polyvictimization framework applied to the study of elder abuse should aim to capture the life span burden of multiple victimiza- tions, not just the burden of multiple, co-occurring forms of abuse in older age. Clearly, additional consensus and research is needed to better define, and sub- sequently understand, relations between various forms of childhood and adult victimization and later elder abuse. In our sample, it is worth highlighting that fully 93.1% of elder polyvictims reported experiencing a prior traumatic event, such as a major accident and/or natural disaster, but we did not specifically assess prior experience of other forms of victimization, per se. Thus, future research is needed to more fully understand the associations between early life victimization and late life abuse and the cumulative impact of multiple victim- ization experiences across the life span.

An important first step in any successful prevention or intervention effort is identifying risk factors, and several important correlates of elder polyvic- timization were noted in this study. In particular, elder polyvictims were more likely to need Helpance with ADLs, have limited social support, and report experiencing traumatic events in the past. Whereas the experience of prior traumatic events is, by temporal necessity, a proxy for other factors that con- tribute to risk of polyvictimization, and thus does not illustrate a directly actionable intervention, the second and third unique risk factors, problems with ADLs and low social support, speak directly to potential intervening steps. Specifically, if factors that impede successful ADL completion, such as ambulation, strength, and resource access are directly related to polyvictim- ization, intervention at the level of these factors, or intervention in the form of efforts to mitigate their impact, may be useful. For example, proactively arranging for social service Helpance, transportation Helpance, and house- hold engineering (e.g., modifying kitchen areas for independent meal prepa- ration) may prevent multiple forms of abuse. Other putative risk factors identified in bivariate analyses included poor health, being a racial minority, and low income, although, in follow-up analyses, these risk factors did not distinguish older adults experiencing a single form of victimization from elder polyvictims. So, these variables may increase risk for experiencing abuse and mistreatment more generally, rather than polyvictimization more specifically, but nonetheless should be included in future studies to determine which factors are most strongly associated with elder polyvictimization.

In considering limitations of this study, there are a number of known risk factors for elder abuse that were not assessed here. For example, some other known risk factors include dementia, frailty, chronic medical conditions, and living with other people (see Johannesen & LoGiudice, 2013, for review). Future efforts to identify risk factors for elder polyvictimization should

4530 Journal of Interpersonal Violence 35(21-22)

attempt to identify the unique risk posed by these factors relative to risk fac- tors identified in this study. We also lacked information about specific subcat- egories of racial and ethnic identity that may help shed further light on the prevalence of elder polyvictimization, especially given that estimates seem to vary widely as a function of various sociocultural factors (e.g., DeLiema et al., 2012; Wu et al., 2012). Other notable limitations of this study center on the single or sole source report of abuse experiences, absence of any cross source collaboration, and more importantly, failure to consider abuse fre- quency (i.e., number of mistreatment episodes) alongside abuse type and polyvictimization. It is very likely the combination of frequency and type that is most predictive of negative outcomes, and such complex analyses will likely be most informative to future intervention efforts.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by the National Institute of Justice (Grant 2007-WG-BX-0009) and by the National Institute on Aging (Grant R21AG030667).

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Author Biographies

Joah L. Williams, PhD, is an Helpant professor in the Department of Psychology at the University of Missouri – Kansas City. His clinical and research interests include the assessment and treatment of trauma-related mental health problems across the lifespan.

Elise H. Racette, MA, is a clinical psychology doctoral candidate at the University of Missouri – Kansas City. Her research interests include examinig the role of trauma across the lifespan on physical and mental health outcomes and the Assessment of fac- tors associated with successful cognitive and psychological interventions.

Melba A. Hernandez-Tejada, DHA, is a research instructor at the College of Nursing at the Medical University of South Carolina. Her research experience and interests span multiple topics, including increasing health care utilization and engagement in treatment for both mental and physical health conditions through innovative use of social support and telehealth.

Ron Acierno, PhD, is a professor and associate dean for research in the College of Nursing at the Medical University of South Carolina and a senior clinical research scientist at the Ralph H. Johnson Veterans Affairs Medical Center. His research port- folio includes both epidemiological studies of elder mistreatment and clinical trials for trauma-related mental health disorders.

https://www.metlife.com/assets/cao/mmi/publications/studies/2011/mmi-elder-financial-abuse.pdf
https://www.metlife.com/assets/cao/mmi/publications/studies/2011/mmi-elder-financial-abuse.pdf
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https://www.justice.gov/elderjustice/support/faq#what-is-elder-abuse
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http://www.preventelderabuse.org/whcoaging2005.html