A Response to the
Abuse of Vulnerable Adults:
The 2000 Survey of State Adult Protective Services
(report review)

published by The National Center on Elder Abuse
no date
reviewed by Loree Cook-Daniels

It’s been seven years since the National Center on Elder Abuse collected APS data from all the states, and this particular report was eagerly awaited: for the first time, it included statistics on abuse of vulnerable adults as well as elders, and it asked a great many questions that hadn’t been asked before.

Unfortunately, the results aren’t nearly as helpful as we might have hoped. A companion AAR article by researchers Jeanette M. Daly, RN, PhD, and Gerald Jogerst, M.D., “Caveats for Consideration When Reviewing 2000 Survey of State APS,” explains some of the inherent problems with collecting adult protective services (APS) data, given our current federal/state system’s many divergent definitions and states’ varied data-gathering and -analysis abilities (for instance, only one state was able to answer all of the survey’s 60 questions; only 16 states could answer 85% or more of the questions). But there are additional problems with the report. The most glaring is its assertion in five places (pp. vii, 3-4, 12, 47, 50-51) that “a few programs serve only adults ages 18-59 who have disabilities that keep them from protecting themselves.” Which states do not serve elders varies, depending upon which page you consult. They are variously identified as Alaska, Arkansas, the District of Columbia, Idaho, Indiana, Michigan, Mississippi, Nebraska, New York, and Ohio. On page 12, the report says that there are 11 states that, programmatically, do not serve elders; which states these are are not listed. This page does contain a caveat that suggests assertions elsewhere in the report may be incorrectly portrayed: “In one state, ‘adult only’ might be restricted to a specific age range, (e.g., 18-64). In another, ‘adult’ might apply to any person who meets the statutory criteria for eligibility for protection, (e.g., vulnerability or disability, regardless of the person’s age), and therefore, encompass a specific population of elderly and/or vulnerable persons.” In fact, an AAR review of elder abuse/vulnerable adult abuse laws for the listed states shows that all of them cover elders.

(The Director of the National Center on Elder Abuse, the report’s primary author, the legal specialist at NCEA, a primary staff person who worked on the survey, the head of the National Association of Adult Protective Services (NAAPSA), and the AoA’s Project Officer for the NCEA were all contacted by AAR for comment. Three responded. Two acknowledged that survey respondents may have been inaccurate in what they checked; two said they were trying to find out through the questions where statutory research was (as one put it) “wrong or out of date” or “where practice and the law don’t coincide.” All admitted no follow-up had been done to explain the unusual findings. No clarification by NCEA is planned; “that will depend on the next NCEA grantee.” The executive director of NAAPSA did say she did not know of any states that are “not providing elder abuse services of some sort.”)

Because of the report’s inaccuracy in the most basic data imaginable -- whether all states address elder abuse -- AAR’s initial excitement over some of the report’s findings had to be tempered. We were delighted to at last see an updated list of who are mandatory reporters in each state, for instance, data that has not been made available by NCEA since at least 1998. There is also a discussion of whether state laws allow for the imposition of a fine, jail sentence, and/or report to a professional licensing board for failure to report abuse; a chart of the “Structure of the State Administrative Agency for Elder/Adult Protective Services”; and a chart of the scope of investigatory authority -- all settings, domestic settings, institutional settings, mental health/mental retardation settings, and other -- for APS programs. Although this information is invaluable in trying to understand the overall national response to elder and vulnerable adult abuse, it might be a mistake to rely upon its accuracy.

Keeping in mind the accuracy concerns described above and in “Caveats...,” and noting that no year can be attached to the data since states were asked to report “the most recent year for which data were accurate and available” (surveys were answered from March through August, 2000), there is some fascinating data in this report. Here are the highlights.

• Categories of abuse. As with most studies that include it as a category, self-neglect is the most common type of abuse: 39% of investigated allegations (N = 118,447) were of self-neglect. Caregiver neglect/abandonment was the second-largest category of allegation, at 19% (N = 59,489), followed by financial abuse/exploitation (13%, or 38,714 investigated allegations). Physical abuse made up 11% of allegations (N = 34,680). Ten percent of allegations (N = 31,298) were classified as “other” (which the report says includes confinement, isolation, and denial of essential services). Emotional/verbal abuse allegations made up 7% of all allegations (N = 20,690); sexual abuse made up only 1% of allegations (N = 4,150).
• Number of reports and cases substantiated. As discussed in “Caveats...,” language confusion and data inadequacy make it impossible to determine how many of the potential cases of elder/vulnerable adult abuse reported to state APS agencies are screened out and/or not investigated. Although some states did provide different numbers for “reports received” and “reports investigated,” it is known that some states with equal numbers of “received” and “investigated” cases actually do screen out some reports before they are investigated, which means that the “total number of reports received” by the states is probably more than the published 472,813. In addition, this figure indiscriminately combines data from the 48.1% of states where reports were only counted if there was no open case with data from the 42.6% of states where the reported number includes additional reports on open cases.

  Based on the 41 states that could report both how many cases they investigated and how many they substantiated, the overall national substantiation rate was 48.5%. Individual states, however, ranged from a substantiation rate of 2.2% in Florida to Indiana’s 100%. For the “year” reported, there were 40,156 substantiated cases of abuse of vulnerable adults (defined as 18-59) and 101,057 substantiated cases of abuse of those 60+. Since the total number of substantiated cases reported was 166,019 (with many states not reporting the number of cases they substantiated), it’s clear these numbers are undercounts.

• Who reports. Family members made up the largest of 27 categories of reporters of elder abuse (13.7%), followed by health care professionals (11.1%) and social service agency staff (10.0%). The “other” category made up 9.8% of reporters. Eight percent of cases were self-reported, and five percent came from anonymous sources. Those categories making up less than 1% of referrals were paid caregivers (.5%), long-term care ombudsmen, area agencies on aging, pharmacists, public officials, coroners, EMT/firefighters, psychologists, attorneys, clergy, and bankers (.1%).
• Gender of victims and perpetrators. Although it is often alleged that older women are victimized at rates higher than older men, this report shows that when the 5% of cases where the gender of victim is unknown are excluded, elder women make up 59% of substantiated cases’ victims, and elder men make up 41% -- exactly their proportions in the 65+ population. (The breakdowns for disabled younger adults were not made available.) Perpetrators, on the other hand, were more often men: in the substantiated cases (not clear if these were of all ages or only elder abuse cases), men made up 61% of identified perpetrators, while women made up 39%.
• “Types” of perpetrators. Spouses/intimate partners made up the largest category of abusers in substantiated cases: 30.2%, followed by adult children (17.6%). All told, 61.7% of perpetrators were family members, although this percentage was calculated on a total that included large numbers of “not known” and “other” perpetrators (third and fourth largest categories, respectively). Although the report says only 4.4% of perpetrators are facility and institution staff, it is not clear who is included in the fifth-largest category of “service provider” (8.2% of perpetrators).
• APS agency placement. In the majority of states, this report says, APS is housed somewhere other than the State Unit on Aging. SUAs, either housed within a human services agency or housed separately, oversee APS in 41% of states (22). In 35% of states -- 19 -- APS is in the human services agency and the SUA is housed elsewhere. In another 19% of states (10), both the APS and the SUA are in the human services agency, but are separate entities. (Because the report’s chart of this data is mislabeled and therefore misleading, AAR has reconfigured the pie chart appropriately below.)
  

• Scope of agency. In the majority of states (31, for 57.4%), APS is reportedly responsible for investigating all elder/vulnerable adult abuse reports, regardless of whether the victim lived in his or her own home or an institution. More specifically, 68.5% of programs investigate nursing home abuse (N=37) and 64.8% (N=35) investigate reports originating in mental health/mental retardation settings.
• Mandated reporters. Half or more of the states mandated that the following professionals report suspected cases of elder/vulnerable adult abuse: physicians, nurses, nursing home staff, dentists, registered nurses, home health personnel, social workers, psychologists, law enforcement officers, health care professionals, nurse aides, and mental health workers.
• Sanctions for failure to report. In one-fifth of states (20.4%, N = 11), there is no statutory consequence for a mandated reporter failing to report. Of states that do have sanctions, 45% (N = 19) provide for a possible misdemeanor penalty, jail sentence, and/or fine. In 24.0% (N = 10), punishment could include a misdemeanor finding and/or a fine. In 17.0% (N = 7), a misdemeanor, but no fine, is provided for. In 7.0% (N = 3), those found guilty risk a misdemeanor finding, a fine, and/or a report to the appropriate professional licensing board. Possible fines ranged from $100 to $10,000; sentences could be from ten days to one year. Only 9 of the respondents (16.7%) said they knew their states had prosecuted someone for failure to report.
• Investigation time frames. Virtually every state (96.3%) sets out time frames during which an investigation must be begun after a complaint has been received. For emergency cases, these ranged from “immediately” (13 states) to 48 hours (2 states). Fifteen states said there was no cap on how long an investigation could take; for the others the investigation cap ran from 10 days (2 states) to 120 days (1 state).
• Abuse registries. With five states not providing data, 21 states (38.9%) maintain an abuse registry or database, and 28 (51.9%) do not.
• How long cases are open. The average length of time an elder/vulnerable adult abuse case was opened ranged from 5 to 216 days, with an overall average (for the 22 states reporting) of 80.5 days.
• Refusal of services and court interventions. Overall, 11.0% of victims refused APS services, with individual states (23 of them) reporting rates from 0 to 35%. An average of 7.0% of cases involved court interventions or legal actions, with the individual states reporting percentages of 1.0% to 18.0%.