Our Elderly: A Public Health Issue in Tucson, Arizona MSA
The U.S. Census Bureau projects that we will reach a demographic milestone for the first time in 2034: the number of people over 65 (77 million) will outnumber the population younger than 18 (76.5 million). That rapid increase in the older adult population underscores the need to ensure that all seniors’ rights, necessities, and freedoms are adequately protected. In this context, a high priority for our society must be to increase awareness of elder abuse - both physical and psychosocial consequences- and seek ways to mitigate it. Figure 1 illustrates the projected number of children and older adults through 2060 using the 2016 Census population as the basis.
Figure 1: Projected Number of Children and Older Adults (2016-2060)
According to the Centers for Disease Control and Prevention (CDC), “Elder abuse is an intentional act or failure to act that causes or creates a risk of harm to an older adult. An older adult is someone aged 60 or older. The abuse often occurs at the hands of a caregiver or a person the elder trusts.” The World Health Organization claims that this type of violence constitutes a violation of human rights.
According to the National Center on Elder Abuse, different cultures, perspectives, and disciplines make it difficult to agree on a universal definition of elder abuse. This lack of uniformity stands in the way of researchers’ efforts to document elder abuse and understand historical trends. Therefore, it is difficult to determine the magnitude of elder abuse nationally and to compare this growing societal concern across states, MSAs, counties, and cities.
Risk Factors for Elder Abuse
Elder abuse is associated with particular risk factors. According to the Panel to Review Risk and Prevalence of Elder Abuse and Neglect of the U.S. National Research Council, risk factors can be categorized into three general groups: factors validated by substantial evidence, possible risk factors (evidence is mixed or limited), and contested risk factors (lack of evidence). Figure 2 displays the risk factors associated with elder abuse by category. Furthermore, it is necessary to clarify that elder abuse is a complicated phenomenon where each situation is unique, with particular risk factors differentiating each case.
Figure 2: Risk Factors Associated with Elder Abuse
According to the U.S. Census Bureau, Population Estimates and Projections, the population aged 65 and older in the United States reached 52.8 million in 2021, representing 16.0% of the total population. In 2021, the Tucson MSA posted a larger percentage of the population aged 65 and older, coming in at 19.8%, than the state and the nation, at 17.6% and 16.0%, respectively (see Figure 3).
Figure 3: Percent of Population Aged 65 and Older in the U.S., Arizona, Tucson, and Phoenix MSAs (2021)
In the U.S., the population aged 65 and older is expected to grow to 73.1 million by 2030, representing about 20.6% of the total population. By 2060 there will be about 94.7 million older adults, a 170% increase relative to 2000 (see Figure 4). The number of centenarians (i.e., people aged 100 and over) was 82,000 in 2016 and is anticipated to reach 589,000 in 2060. Therefore, the elderly population itself will become progressively older. Please note: increments in years are uneven. The years 2040 and 2060 indicate projections.
Figure 4: Number of Persons Aged 65 and Older, 1900-2060 (Numbers in Millions)
Despite the lack of consensus on what constitutes elder abuse, all 50 states report to adult protective services (APS) cases of abuse, neglect, and exploitation. The National Adult Maltreatment Reporting System (NAMRS) is a consistent and accurate database for state APS programs.
According to the Adult Maltreatment 2021 report by the NAMRS, 59.1% of reports were accepted for investigation. Of those reports accepted, 59.2% were submitted by professionals, 15.8% by relatives, 4.7% self-reported, and 12.8% other. The source was unknown or unidentified in 7.5% of investigations. The percentage of reported allegations of self-neglect (50.0%) ranked first among other maltreatment types. Figure 5 shows the percent of allegation types in the U.S. (2021).
Figure 5: Percent of Allegation Type in the U.S. (2021)
Considerable variation exists when comparing the type of maltreatment of substantiated cases across Western states. Among all types of maltreatment, self-neglect accounted for the largest percent in most states. In 2020, Washington ranked first in this type of maltreatment with 84.0%, and Utah posted the smallest percentage at 6.7%. Texas had the smallest rate of exploitation among victims, at 1.9%, while Arizona had the highest rate at 58.4% (see Figure 6).
Figure 6: Percent of Maltreatment Substantiated Cases in the U.S. and Western States (2020)
The gender distribution data in the 2021 adult maltreatment report showed that, among substantiated cases, women in the U.S. are more likely to be victims of abuse than men. When compared by the different types of abuse, women sustained more physical abuse than men (63.6% for women vs. 35.6% for men), emotional abuse (70.0% vs. 28.8%), sexual abuse (80.7% vs. 17.2%), and exploitation (56.6% vs. 38.5%).
In Arizona, 6,919 cases were opened for males (40.0%), while 10,175 were opened for females (58.8%) in 2021. The prevalence of female reports in Arizona (58.8%) exceeded the national rate by over two percentage points. The Tucson MSA reported a trend similar to the state, with 59.3% of reported cases being females and 39.6% reports for males (Figure 7).
Figure 7: Percent of Reported Cases of Elder Abuse by Gender (2021)
Regarding disabilities, among the 113,696 total cases reported in the U.S. in 2021, the most frequent type of disability in victims of maltreatment was ambulatory difficulties (31.9%), defined as having difficulty walking or climbing stairs. That was followed by cognitive issues, with a 20.8% prevalence among all reported cases. For 39.9% of older adult victims of maltreatment, the type of disability was unknown. In Arizona, among 17,317 cases, 76.2% had physical difficulty, and 71.1% had cognitive or mental issues. The Tucson MSAs posted a similar percentage of physical difficulty (76.0%) and cognitive/mental difficulty (71.6%). Note that case reports may include more than one type of disability per individual (Figure 8).
Figure 8: Percent of Reported Cases of Elder Abuse by Disability Type (2021)
The living arrangement of individuals where APS had investigated substantiated allegations of maltreatment varied from state to state. Based on 2021 data from 22 states, 69.6% of victims reported maltreatment in their own or private residences, followed by 7.9% in licensed/unlicensed residential care. Unknown was listed as the setting for 14.4% of the victims (Figure 9). Please Note: Based on victim data submitted by 22 states for 68,446 victims. In states where investigation of alleged adult maltreatment in residential care facilities does not fall under APS jurisdiction, regulatory or licensing agencies conduct the investigations
Figure 9: Percent of Victims by Setting of Reported Maltreatment Type (2021)
According to NAMRS, a perpetrator is a person determined to be responsible for one or more maltreatment cases considered substantiated. Nationally, 10.5% of the perpetrators in 2021 were between ages 50-59, followed by 40-49 (9.6%). For 48.0% of older adult victims of maltreatment, the age of the perpetrators was unknown.
Substantial variation existed in the maltreatment type by gender. Women perpetrators were 14.0 percentage points higher than men in cases of neglect, nearly seven points higher in cases of exploitation, and 13.5 points higher in cases of abandonment. On the other hand, male perpetrators were 58.2 percentage points higher than females in cases of sexual abuse, 16.6 points higher in cases of physical abuse, and 14.1 points higher in cases of emotional abuse.
According to national victim-perpetrator data in 2021, 23.0% of perpetrators had no familial relationship with the victim. By contrast, in Arizona, 37.1% of perpetrators had a familial relationship with the victim, followed by 31.7% of cases where the perpetrator was either a caregiver or resident manager (See Figure 10).
Figure 10: Types of Victim-Perpetrator Relationships (in percent) in Arizona (2021)
The Implications of Elder Abuse
The National Center on Elder Abuse (NCEA) classifies the consequences of abuse into five categories: physical, psychological, sexual, financial, and neglect. Physical and emotional consequences include health issues, distress, perceived self-efficacy, feelings of powerlessness, depression, anxiety, and even post-traumatic stress disorder (PTSD)1,2.
Concerning financial consequences, the direct medical costs of injuries caused by elder abuse are estimated to contribute more than $5.3 billion to the nation’s annual health expenditures3. The financial impact of maltreatment relies on government resources such as Medicaid to pay for long-term care in the event a case is covered. In many situations, however, victims of elder abuse do not qualify for Medicaid because of the five-year “look back” rule of coverage for finances before the claim of exploitation.
In 2010 the annual economic impact of financial abuse on older adults was over 2.9 billion dollars, according to The MetLife Study of Elder Financial Abuse. That constituted a net 12% increase since 2008.
One of the five priorities enumerated in “Tackling abuse of older people: five priorities for the UN Decade of Healthy Ageing (2021–2030)” to prevent and respond to abuse of older adults is to combat ageism or age discrimination. Ageism is one of the most prevalent and least recognized forms of stereotyping and discrimination in modern society; and an important reason why elder abuse gets so little attention.
According to the National Center on Elder Abuse, the consequences of ageism among older adults are poorer medical and mental health outcomes, significant monetary losses, increased loneliness, social isolation, environmental stressors, and employment discrimination. Concerning discrimination in the workplace, a landmark study published by Stanford University Business School, “Workplace Equality for All! (Unless They're Old)”, concluded that people who oppose racism and sexism are reluctant to eradicate ageism in the workplace. Furthermore, the data show that the younger you are, the more you endorse the idea that ‘older workers should step aside and make way for the younger’.
How Can We Prevent Elder Abuse?
We can all help by understanding and addressing the factors that put older adults at risk. The CDC Division of Violence Prevention enumerates a list of actions that can help to prevent violence against older adults. For example, listening to older adults and their caregivers to understand their needs and challenges.
Please see the links below for information on identifying abuse and what to do to find help to report physical and other abuse.
1Comijs HC, Penninx BW, Knipscheer KP, van Tilburg W. Psychological distress in victims of elder mistreatment: the effects of social support and coping. J Gerontol B Psychol Sci Soc Sci. 1999 Jul;54(4):P240-5. doi: 10.1093/geronb/54b.4.p240. PMID: 12382593.
2Acierno, R. National Elder Mistreatment Survey: 5-Year Follow-up of Victims and Matched Non-Victims. Report number 252029 to the National Criminal Justice Reference Service by the Medical University of South Carolina, 2018, 13 pp.
3Dong X. Medical implications of elder abuse and neglect. Clin Geriatr Med. 2005 May;21(2):293-313. doi: 10.1016/j.cger.2004.10.006. PMID: 15804552.