INTRODUCTION

The study of elder mistreatment has come quite far in the 35 years since the medical community first described its impact on older adults. From the first reporting of “granny battering” by a physician in a letter to the British Medical Journal, this field of study has grown remarkably over the last few decades.¹ Known as “elder abuse” in the past, the condition involving exploitation, neglect and abuse, is now more commonly identified as “elder mistreatment” in recognition of its syndrome-like construction.

With a greater understanding of the subtypes of elder mistreatment, we enter a new decade with a focused agenda for identifying, treating, and preventing all of its subtypes. In 2010, the United States (U.S.) Congress passed the Elder Justice Act (EJA) as part of healthcare reform, defining mistreatment as entities of abuse, exploitation, neglect, self-neglect, serious bodily injury and criminal sexual abuse (Table).^3,4 The EJA definitions concur with the World Health Organization’s (WHO) recognized entities of sexual abuse, neglect, and bodily injury (physical abuse), and the WHO further defined exploitation as “financial or material abuse.”⁵ In the same report, the WHO further defines violence as “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group…that results in or has a high likelihood of or resulting in injury, death, psychological harm, maldevelopment, or deprivation.” The idea that elder mistreatment is a violent act has been widely publicized, but under the WHO definition, the concept of deprivation emphasizes that acts of omission, or neglect, are just as violent as acts of commission (including physical, sexual, and verbal abuse). In a 2009 study on domestic violence, the World Bank went further to restate financial exploitation as financial violence. The more active term “violence” helps reinforce the perpetrator/victim dynamic as negative and implies that this is a forceful act. Financial violence is defined as “denying a victim access to or control over material goods, basic resources, and assets,” establishing the use of force in the creation of a harmful environment for the victim.⁶ This definition reappears in the EJA, supporting a more global view of financial exploitation by denial as a violent crime.

FINANCIAL EXPLOITATION

Current research demonstrates that financial exploitation occurs in a majority of elder mistreatment cases. In the past, many studies had not significantly identified financial exploitation as part of elder abuse leading to the assumption that it was a relatively minor form of mistreatment.⁷ Newer prevalence studies in the U.S. and Europe reveal that financial exploitation is one of the more common forms of elder mistreatment. In 2008, data published by the National Social Life, Health and Aging Project identified a 3.5% prevalence of financial mistreatment in the U.S., ranking it the second most common form of elder mistreatment after verbal abuse.⁸ The United Kingdom (U.K.) National Prevalence Study, published in 2009, also identified financial exploitation as the second most common form of abuse (after neglect).⁹ A year later, data from the U.S. National Elder Mistreatment Study identified a prevalence of 5.2% for financial mistreatment, outranking emotional, physical or sexual mistreatment.¹⁰ Most recently, the New York State Elder Abuse Prevalence Study demonstrated a 4.1% prevalence for major financial exploitation, making it the most common form of elder mistreatment in that study as well.¹¹

Individual cases demonstrating a link between financial exploitation and harm can be found worldwide. A recent case in Georgia featured a disabled older woman denied potentially life-saving medical attention after a serious fall as the caregiver withdrew large sums of cash from the victim’s bank using a forged power of attorney document.¹² A formerly independent elderly couple in Ireland found their finances drained as their son withheld food, clothing and medications from them over a six month period.¹³ As an abuser restricts access to financial resources, the victim may become unable to afford medications, basic utilities, shelter, and even food, possibly contributing to the compromise of chronic medical illness or the development of new conditions such as malnutrition. At this point, research has not demonstrated a true causal relationship between financial exploitation and worse health outcomes, presenting one of the greatest challenges in this field.

Researchers Karch and Nunn¹⁴ recently described one potential method to study the link between financial exploitation and health outcomes. They used the U.S. National Violent Death Reporting System and identified 68 cases of death due to elder mistreatment. Seventeen of those deaths were due to neglect by a caregiver; two of those cases were motivated by financial gain. In the 21 cases of physical injury, at least one had a motive of financial gain. However, since financial mistreatment is currently not defined as a violent crime it was not listed as the cause of death in those cases. Karch and Nunn¹⁴ were also unable to state specific identifiers of financial exploitation, another hurdle facing further research.

DISCUSSION

Financial exploitation is now recognized as a major subtype of elder mistreatment. This realization creates several new questions. Is financial exploitation a violent crime – financial violence – per se? Some organizations seem to be making that connection. Since the passage of the Elder Justice Act, we now have legal description of it as an act of violence. What is the relationship of financial exploitation to physical forms of abuse? It is possible that financial exploitation could be an early warning sign of potential physical abuse, and may present a point of action for secondary prevention of elder mistreatment? Finally, does elder financial exploitation lead to worse health outcomes? While it is possible that financial exploitation might predict physical abuse, there are many cases where financial exploitation does not lead to identified physical, sexual, or verbal abuse. However, in those cases, we may find evidence of harm when compared to non-exploited elders. A connection of direct harm would support the medical description of financial exploitation as a violent act.

The possibility that financial exploitation may precede physical harm presents an opportunity to intervene at an early stage of the abuse cycle. Current proposed screening tools to detect elder mistreatment are significantly limited in efficacy.¹⁵ Yet, a detection program within our banking system, focusing on a specific pattern of financial activity, could detect elder mistreatment at an earlier stage if the theory is proven.

CONCLUSION

Research has identified financial exploitation as one of the most common forms of elder mistreatment. With a prevalence of more than double that of physical abuse, financial exploitation might be an essential early warning sign appropriate for use in screening. Catching financial exploitation early (potentially by using systems similar to current financial fraud detection) presents an opportunity for intervention, protecting the financial assets of the victim and possibly preventing physical harm and loss of independence.¹⁶ A better understanding of financial exploitation from a public health perspective, including definition, is needed. Future studies must also assess if worse health outcomes are associated with financial exploitation itself. If so, then financial exploitation might truly be a violent crime and validate the term financial violence in more than just the legal perspective.

Footnotes

Special thanks to Drs. Ted Johnson, Mark S. Lachs, and Brian Payne for their assistance in the preparation of this material. Supported in part by the ECIC Faculty Seed Grant Program from the Emory Center for Injury Control, Emory University; CDC Grant #5R49CE001494.

Supervising Section Editor: Monica H Swahn, PhD, MPH
Submission history: Submitted: January 15, 2011; Revision received February 3, 2011; Accepted February 22, 2011.
Reprints available through open access at http://escholarship.org/uc/uciem_westjem.

Address for Correspondence: Thomas Price, MD
Wesley Woods Health Center, 1841 Clifton Road NE, Suite 534, Atlanta, GA 30329
Email: tprice2@emory.edu.

Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources, and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none.

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