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doi:10.1111/psyg.12009
REVIEW ARTICLE
Theories and measures of elder abuse
Yadollah ABOLFATHI MOMTAZ,1 Tengku Aizan HAMID1,2 and Rahimah IBRAHIM1,2
1
Institute of Gerontology and 2Department of
Human Development and Family Studies, Faculty
of Human Ecology, Universiti Putra Malaysia,
Serdang, Malaysia
Correspondence: Dr Yadollah Abolfathi Momtaz PhD,
Institute of Gerontology, Universiti Putra Malaysia,
43400 UPM, Serdang, Selangor, Malaysia. Email:
yabolfathi@gmail.com
Received 12 September 2012; revision received 5 March
2013; accepted 12 March 2013.
Key words: aged, elder abuse, measurement,
theory.
INTRODUCTION
As the population ages, it is imperative to pay more
attention to the issues affecting older adults’ quality
of life and psychological well-being.1–4 A pervasive
phenomenon across the world with devastating
effects, elder abuse is associated with decreased
quality of life and increased morbidity and mortality
rates.5 Although it is not a new phenomenon, aware-
ness of elder abuse and interest in examining the
problem are relatively new. International studies
estimate that 1–5% of community-dwelling elderly
people aged 65 years and older suffer from abuse or
at risk of being abused.6 According to the World
Health Organization, elder abuse is defined as a
‘single or repeated act, or lack of appropriate action,
occurring within any relationship where there is an
expectation of trust, which causes harm or distress
to an older person’.7 The goal of this review article is
twofold: (i) to provide an overview of the theories
might explain elder abuse; and (ii) to train health-
and social-care providers and researchers about
selecting and using existing elder abuse measure-
ment instruments.
182
PSYCHOGERIATRICS 2013; 13: 182–188
Abstract
Elder abuse is a pervasive phenomenon around the world with devastating
effects on the victims. Although it is not a new phenomenon, interest in
examining elder abuse is relatively new. This paper aims to provide an
overview of the aetiological theories and measures of elder abuse. The paper
briefly reviews theories to explain causes of elder abuse and then discusses
the most commonly used measures of elder abuse. Based on the reviewed
theories, it can be concluded that elder abuse is a multifactorial problem that
may affect elderly people from different backgrounds and involve a wide
variety of potential perpetrators, including caregivers, adult children, and
partners. The review of existing measurement instruments notes that many
different screening and assessment instruments have been developed to
identify elders who are at risk for or are victims of abuse. However, there is
a real need for more measurements of elder abuse, as the current instru-
ments are limited in scope.
THEORIES OF ELDER ABUSE
The first section of this article attempts to theorize the
causes of elder abuse and why elderly people are
vulnerable to abuse. Thus, theories from different dis-
ciplines, such as psychology, sociology, and biology,
are presented to explain why elder abuse occurs.
Table 1 presents a summary of the theories.
Social exchange theory
Social exchange theory supposes that two parties are
both giving and receiving items of value from each
other and that the interaction between two parties will
be positively evaluated if both parties benefit equally
from the relationship. According to this theory, elder
abuse may occur because of the victim’s dependence
on the abuser and vice versa. First, it is assumed that
elder abuse is the result of the elder’s increasing
dependence the caregiver. As people age, they
become more powerless, vulnerable and, to some
degree, dependent on family members for assistance,
which may increase the risk of abuse. A caregiver may
resent that the older person is completely dependent
on the caregiver; the caregiver may experience anger
© 2013 The Authors
Psychogeriatrics © 2013 Japanese Psychogeriatric Society
 Theories and measures of elder abuse

Table 1 Summaries of elder abuse theories

Name of theory
8–10
Social exchange theory
Feminist theory11
Political economic theory12
Psychopathology of the
caregiver theory13,19
Role accumulation theory14
Situational theory15
Social learning theory16,17
Stratification theory18
Symbolic interactionism theory20–22
Key element Descriptions
Dependency Elder abuse is the result of the elderly’s increasing on the caregiver and
vice versa.
Patriarchal family Elder abuse is the product of a patriarchal family.
Dependency The changing role of the elderly removes them from the workforce and
reduces their independence, which may lead to elder abuse.
Caregiver pathology The abuser’s behavioural characteristics contribute to elder abuse.
Environmental stress Family members with conflicting role obligations are not able to effectively
manage stress in their lives. These strained family members may abuse
an older adult as a way of coping with their stress.
Caregiver stress An overburdened caregiver who cannot cope with the demands of caring
creates a situation for abuse.
Learnt abusive Violence is a learnt behaviour that may pass down from generation to
behaviour generation.
Caregiver stress Caregivers’ low job satisfaction and low levels of education may contribute
to elder abuse.
Culture Cultural values and expectations influence what behaviour is considered
abusive.

that leads to abusive behavior.8 For example, if the
caregiver perceives himself or herself as deserving of
rewards for supporting that elderly person, abuse may
occur if such rewards are denied. It has also been
postulated that elder abuse is the result of a care-
giver’s increasing financial dependency on the elderly
person. Owing to a sense of imbalance in the relation-
ship and the violation of social expectations concern-
ing independent adult behaviours, the perpetrator
tries to restore some sense of control with violence or
threats of violence.9,10
Feminist theory
Feminist theory focuses on spousal elder abuse as a
significant dimension of elder abuse, wherein older
women are more vulnerable to spousal abuse
because older women tend to have less power than
men. According to this theory, men have more social
and financial resources and regard women as their
property.11
Political economic theory
This theory addresses that elderly people are gradu-
ally marginalized in their families and society. There-
fore, they lose their role and depend on others.
According to political economic perspective, the
changing role of the elderly removes them from the
workforce and reduces their independence, which
may lead to elder abuse.12
Psychopathology of the caregiver theory
This theory examines the role of the caregiver with a
mental health problem and how that puts elders at risk
for mistreatment.19 According to this theory, the
abuser’s behavioural characteristics contribute to
elder abuse. Caregivers who consumed alcohol and
experienced depression and anxiety are more likely to
use physical and verbal abuse against the elder.13
Role accumulation theory
This theory argues that elderly people may be abused
by family members including their spouse, adult chil-
d(ren), or son- or daughter-in-law. According to the
role accumulation theory, family members with con-
flicting role obligations are not able to manage the
stress of their own lives. These stressed family
members may abuse an older adult as a way to cope
with their stress.14
Situational theory
Situational theory is one of the earliest and most widely
accepted explanations of elder abuse. This theory
focuses on the role of stress and the burden of caregiv-
ing in elder abuse. According to this theory, an over-
burdened caregiver who cannot cope with caring
demands creates an environment for abuse. Overall,
this theory supports the idea that stressed caregivers
may become abusive towards their vulnerable
seniors.15

© 2013 The Authors 183

Psychogeriatrics © 2013 Japanese Psychogeriatric Society
Y. Abolfathi Momtaz et al.
Social learning theory
Social learning theory, also called the transgenera-
tional theory, postulates that violence is a learnt
behaviour that may be passed down from generation
to generation. When children observe violence as a
response to stress, they then internalize this behav-
iour as acceptable. In the case of elder abuse, an
abused child may abuse her or his parents in the
future. In addition, when an abusive spouse becomes
ill or disabled, the previously abused partner may
abuse him or her. Thus, the child or spouse who was
abused by the parent or spouse continues the cycle of
violence as a caregiver.16,17
Stratification theory
Within this theory, elder abuse is particularly inflicted
by caregivers. According to stratification theory, jobs
at the bottom of the stratified system are not desirable
because of their low status and pay, but they are
needed in order to survive. Caregivers for the elderly
receive low pay, and their job title has little prestige,
regardless of where the job is done. It can be
expected that elder abuse occurs when the caregiver
tries to control the older person. When the caregiver
must override the elder’s wishes, which could be
influenced by dementia, the elderly person may resist
the caregiver. With little status, the caregiver may feel
the need to gain control over the elder. Within the
stratification theory, it can be assumed that a care-
giver’s low job satisfaction and low levels of education
may contribute to elder abuse.18
Symbolic interactionism theory
Symbolic interactionism is the way people react and
view the world through their interactions with others.20
This theory can be used to explain why elder abuse
takes place and how culture plays an important role in
the perception of abuse. According to this theory,
every object has different meaning to each person,
and everyone has his or her own way to find meaning.
Therefore, perception and interpretation of an object
is not always same for all people. According to this
perspective, cultural values and expectations influ-
ence what conduct is considered to be elder abuse.21
For example, in some cultures, sending elderly indi-
viduals to nursing homes is considered to be a form of
abuse, whereas other cultures define it as a sign of
caring.22
184
MEASURES OF ELDER ABUSE
All relevant literature (released up to August 2012) was
searched based on key words pertinent to the devel-
opment and validation of instruments that measure
elder abuse. Studies describing instrument develop-
ment and validation were retrieved. After full-text
articles were retrieved through electronic databases,
the following information was drawn out: the instru-
ment’s purpose and content; the instrument’s devel-
opment and scoring; and the instrument’s reliability
and validity. Table 2 presents a summary of the
reviewed elder abuse instruments.
American Medical Association screen for various
types of abuse and neglect (AMA-SVTAN)
The AMA-SVTAN is a self-report questionnaire con-
sisting of nine yes-or-no questions to determine
various types of elder abuse: two questions for physi-
cal abuse, three questions for psychosocial abuse,
two questions for financial abuse, and two questions
for neglect. Elder respondents are interviewed by a
health-care professional. A positive answer to each
question is considered indicative of abuse. The
AMA-SVTAN instrument demonstrated a test–retest
reliability of 0.83 and a Cronbach’s a of 0.73.
This assessment tool is usually used in clinical set-
tings. Physicians interview and physically examine
elderly patients to diagnose various types of abuse or
neglect, including physical, psychological, financial,
and material.23
Brief Abuse Screen for the Elderly
The Brief Abuse Screen for the Elderly was developed
by Reis and Nahmiash and contains five items. The
scale has demonstrated good interrater reliability (86–
90%) and substantial predictive validity, ranging from
0.89 to 0.91. This instrument is not time-consuming to
complete (it takes approximately 1 min) and may be
useful in busy environments. However, there is no
established scoring method. One disadvantage of this
scale is that interviewers ideally should have some
knowledge of and training on elder abuse before using
the scale.24 The Brief Abuse Screen for the Elderly asks
screeners to make an educated guess concerning the
presence or absence of physical, psychosocial, and
financial abuse or neglect by a caregiver. It also asks
the screeners to estimate the needed intervention.25
© 2013 The Authors
Psychogeriatrics © 2013 Japanese Psychogeriatric Society
 Table 2 Descriptions of the reviewed elder abuse measurement instruments
Description
Name of scale Authors Number of items Purpose Psychometrics properties Strengths Weaknesses
23
American Medical Aravanis et al. (1993) Nine yes-or-no To measure various types Cronbach’s a = 0.73 Screens for various types No ability to distinguish
Association Screen for questions of abuse or neglect of elder abuse and between cases of elder
Various Types of Abuse neglect abuse and non-cases
and Neglect

© 2013 The Authors

(AMA-SVTAN)
Brief Abuse Screen for the Reis and Nahmiash Five items To assess the likelihood of Not documented Brief, quick and easy to No established scoring
Elderly (1995)24 abuse use, but must be procedure; does not
preceded by extensive assess self-neglect
training on elder abuse
Caregiver Abuse Screen Reis and Nahmiash Eight questions To identify the risk for Cronbach’s a = 0.77 Not time-consuming No established scoring
(CASE) (1995)24 abuse procedure; only the
caregiver answers
questions
Comprehensive Geriatric Bonnie and Wallace Three questions To screen for elder Intrarater reliability = 0.95 Ideal tool for evaluation of Should be conducted by
Assessment (CGA) (2003)26 neglect and abuse abused and neglected a multidisciplinary team;
elderly people time-consuming
Conflict tactics scale Straus (1979)27 19 items To determine elder abuse Cronbach’s a = 0.79 to Measures psychological Not specifically developed
(CTS) 0.95 and physical abuse for elderly people; does
no address neglect

Psychogeriatrics © 2013 Japanese Psychogeriatric Society

Elder Assessment Fulmer (1984)29 41 items To screen for suspected Cronbach’s a = 0.84. Used in all clinical No established scoring
Instrument (EAI) elder abuse victims settings procedure
Elder Abuse Suspicion Yaffe et al. (2008)5 6 questions To raise a doctor’s Sensitivity (0.03 to 0.28) Screens for all types of Low sensitivity
Index (EASI) suspicion about elder Specificity (0.72 to abuse
abuse 0.99)
Health, Attitudes Toward Ferguson et al. (1983)30 37 three-point To identify elders at risk No psychometric Assesses potential factors No established scoring
Aging, Living Likert-type items properties contributing to elder procedure
Arrangements, and abuse
Finances (HALF)
Assessment
Hwalek-Sengstock Elder Neale et al. (1991)28 15 questions To identify people at high Cronbach’s a = 0.63 Easy to use by health and Minimal ability to
Abuse Screening Test risk social service distinguish between
(HSEAST) professionals cases of elder abuse
and non-cases
Indicators of Abuse (IOA) Reis and Nahmiash 22 items To screen for abuse Cronbach’s a = 0.92 Scores information Time-intensive; not used
(1998)31 in long-term care
settings
Older Adult Psychological Conrad et al. (2011)32 31 items (long form) To measure psychological Cronbach’s a = 0.87 Can be used by both Does not assess all types
Abuse Measure 18 items (short form) abuse Cronbach’s a = 0.92 clinicians and of elder abuse
(OAPAM) researchers
The Older Adult Financial Conrad et al. (2011)32 25 items To identify potential Cronbach’s a = 0.93 The only validated Requires adequate
Exploitation Measure financial abuse financial abuse scale cognitive capacity to
(OAFEM) complete
Vulnerability to Abuse Schofield and Mishra 12 items To identify older women at Cronbach’s a = 0.74 to Easy to use and can be Validated with older
Screening Scale (VASS) (2003)33 risk of abuse 0.31 mailed to subjects women
Questions to Elicit Elder Carney et al. (2003)34 15 closed-ended To determine if abuse is Cronbach’s a = 0.83 Easy to use and not No cross-cultural
Abuse (QEEA) questions occurring time-consuming; validation
evaluates physical,
emotional, and financial
abuse and neglect

185
Theories and measures of elder abuse
Y. Abolfathi Momtaz et al.
Caregiver Abuse Screen (CASE)
The CASE is an eight-question screening tool with a
dichotomous (yes/no) scoring method that is com-
pleted by caregivers. Answering ‘yes’ to any question
counts as one point. The points are summed to create
a total score with a possible score range 0–8. A score
of 4 or more indicates ‘abuse likely’. However, depend-
ing on the question, a score of 1 can also be considered
‘abuse likely’. The scale has demonstrated acceptable
to good internal consistency (Cronbach’s a = 0.77).24
According to the CASE, the caregivers are asked to
answer screening questions for physical, psychologi-
cal, and financial abuse or neglect.25
Comprehensive Geriatric Assessment (CGA)
The CGA is an integrated and multidimensional
approach that aims to assess the functional ability,
health, and socio-environmental situation of older
adults. It is also a well-validated procedure for assess-
ment and intervention of abused and neglected
elderly people. The CGA can be performed efficiently
in both inpatient and outpatient settings such as hos-
pitals, outpatient clinics, nursing homes, and private
homes. The assessment is most successful when
done by a multidisciplinary team consisting of a geri-
atrician, nurse, social worker, and pharmacist.26 The
final diagnosis is made based on a combination of
clinical acumen and test scores.19 The greatest limita-
tions of the CGA are that it is time-intensive and only
trained professionals can use it.
Conflict tactics scale (CTS)
The CTS is a 19-item self-report scale that measures
the use of reasoning, verbal aggression, and physical
violence for resolving family and interpersonal con-
flict. It has long been used to determine whether indi-
viduals have been threatened or assaulted. Although
the CTS has demonstrated sound reliability (Cron-
bach’s a = 0.79–0.95),27 it is limited in the elder abuse
context because it has not been specifically devel-
oped for measuring this type of abuse. The CTS asks
respondents to indicate how many times they have
been assaulted by or assaulted their partner in the
past year.
Elder Assessment Instrument (EAI)
The EAI is a 41-item Likert assessment instrument
designed specifically to assess signs, symptoms and
186
subjective complaints of elder abuse, neglect, aban-
donment and exploitation. It can be used in all clinical
settings and is administered by trained nurses and
clinicians. The results of psychometric studies of the
EAI show a content validity index of 0.83, interrater
agreement of 0.83, a specificity of 93%, and a sensi-
tivity of 71%. The internal consistency reliability using
Cronbach’s a has been reported to be 0.84. Although
the instrument has good reliability and validity, there is
no established method of scoring.28 The EAI is com-
pleted by a nurse using a one-to-one interview and
physical assessment of the older person for possible
mistreatment and can be used in all clinical settings.29
Elder Abuse Suspicion Index (EASI)
The EASI, developed by Yaffe et al., is a six-item tool
for physicians to assess suspected cases of elder
abuse and neglect. A positive (yes) answer to one or
more of the questions may establish the presence of
abuse and requires follow-up. The goal of the EASI is
not necessarily to measure elder abuse but to quantify
a level of suspicion so that potentially vulnerable
cases can be referred to a community expert in elder
abuse for further assessment. Because this scale is
easily and quickly administered, it may encourage
doctors to refer possible elder abuse cases for further
assessment. To our knowledge, no Cronbach’s a reli-
ability coefficient has been reported for the EASI.5
Health, Attitudes Toward Aging, Living
Arrangements, and Finances Assessment
The Health, Attitudes Toward Aging, Living Arrange-
ments, and Finances Assessment is an instrument
used to identify elders who are at risk for abuse or
actual victims of abuse. It is administered by health-
care professionals in a clinical setting. This 3-point
Likert-type scale is administrated with both the care-
taker and older adult.19 The instrument was presented
by Ferguson and Beck with no psychometric data.
The instrument assesses four potential factors con-
tributing to elder abuse.30
Hwalek-Sengstock Elder Abuse Screening
Test (HSEAST)
The HSEAST is a 15-question instrument designed to
identify elderly people at high risk of domestic vio-
lence. Respondents are asked to indicate whether
they have experienced or are at risk of experiencing
any of the listed conditions. A response of ‘no’ to
© 2013 The Authors
Psychogeriatrics © 2013 Japanese Psychogeriatric Society

questions 1, 6, 12, and 14; a response of ‘someone
else’ to question 4; and a response of ‘yes’ to the rest
of the questions are scored in the ‘abused’ direction.
Although the HSEAST has demonstrated good test–
retest reliability with a = 0.86 and an acceptable inter-
nal consistency (Cronbach’s a = 0.63), it is limited
because of its high false negative rate. 28
Indicators of abuse
This is a 22-item home-based instrument for measur-
ing abuse. This test is administered by an experienced
and trained interviewer after a 2–3-h home assess-
ment. A score of 16 and over suggests that the elderly
subject is at significant risk for experiencing abuse.
Internal consistency using Cronbach’s a was 0.92,
demonstrating a high level of reliability for the indica-
tors of abuse.31
Older Adult Psychological Abuse
Measure (OAPAM)
The OAPAM has been developed as a comprehensive
measure of elder abuse. The OAPAM consists of
either 31 items (long form) or 18 items (short form). It
is a measure of psychological abuse that is completed
by respondents. The unidimensional measure has
sound reliability and validity in the assessment of psy-
chological abuse of elderly people by both clinicians
and researchers. The Rasch person reliability has
been reported to be high for both the OAPAM long
form (= 0.78, corresponding with Cronbach’s a = 0.87)
and short form (= 0.86, corresponding with Cron-
bach’s a = 0.92).32
Older Adult Financial Exploitation
Measure (OAFEM)
The OAFEM is a 25-item screening tool that identifies
potential financial abuse of older people. This instru-
ment is the only validated financial abuse scale that
assesses several forms of financial abuse, including
theft and scams, financial victimization, coercion,
financial entitlement, signs of possible financial
exploitation, and money mismanagement. The
completion of OAFEM requires adequate cognitive
capacity (i.e. a score of 17 or above on the Mini-
Mental Status Exam) is required. This self-report
instrument is completed by older adults in an inter-
© 2013 The Authors
Psychogeriatrics © 2013 Japanese Psychogeriatric Society
Theories and measures of elder abuse
view. The OAFEM has demonstrated high internal
consistency reliability (Cronbach’s a = 0.93).32
Vulnerability to Abuse Screening Scale (VASS)
The VASS is a 12-item screening instrument with yes-
or-no that is used to identify elderly people at risk of
abuse. The instrument is completed by respondents
and assesses four factors: vulnerability, dejection,
dependence, and coercion. Cronbach’s a is reported
from 0.74 for dependence to 0.31 for coercion, repre-
senting moderate to good reliability. Although the
VASS has been validated with older women and is
considered to be a gender-neutral instrument, it is not
known whether the VASS is also valid for determining
abuse in older men.33
Questions to Elicit Elder Abuse
Questions to Elicit Elder Abuse evaluate the existence
of 15 indicators of abuse based on a respondent’s
questionnaire. This instrument has 15 closed-ended
questions that assess the existence of physical
abuse, emotional abuse, neglect, and exploitation.
For each participant, a total and type of abuse score
is generated by the sum of each ‘yes’ answer. Internal
consistency measured by Cronbachs’ a was reported
at 0.83 for the 15 items.34
CONCLUSIONS
This review aimed to assess theories and measure-
ments of elder abuse. Several theories that might
explain possible causes for elder abuse were identified
and discussed. Based on the reviewed theories,
several factors including caregiver stress (situational
theory; stratification theory), dependency (social
exchange theory), negative attitude (political econo-
mic theory), environmental stress (role accumulation
theory), learnt abusive behaviour (social learning
theory), caregiver pathology (psychopathology of the
caregiver theory), and spousal domestic abuse (femi-
nist theory) cause elder abuse. Additionally, according
to symbolic interactionism theory, cultural values and
expectations influence what behaviour is considered
abusive. Hence, it can be concluded that elder abuse is
a multifactorial, complex problem that affects elderly
people with different backgrounds at the hands of
a wide variety of potential perpetrators including
caregivers, adult children, and partners. Because our
review reveals that no single theory can comprehen-
187
Y. Abolfathi Momtaz et al.
sively explain all causes of elder abuse, developing an
integrated theory with a comprehensive perspective is
recommended.
With regard to the second aim of the study, a
review of existing instruments showed that many dif-
ferent screening and assessment tools have been
developed to identify elders who are at risk for or are
victims of abuse. Elder abuse instruments can be
divided into two basic types depending on whether
the abuse has already happened (to determine actual
victims of abuse), such as AMA-SVTAN, or whether
the abuse may happen in the future (to identify elderly
people at risk of elder abuse) including HSEAST,
VASS, and CASE. Therefore, in elder abuse studies it
is important to be aware of the instrument’s purpose
and reliability and validity for the population studied.
These instruments may not be appropriate cross-
culturally. As such, there is a real need to develop
measures for elder abuse that might have core indi-
cators that are universal and sub-indicators that may
be appropriate for certain situations.
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© 2013 The Authors
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