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2012 WEBINAR SERIES PART II: TACKLING THE TOUGH TOPICS IN

ETHNOGERIATRICS

Please visit our website for more informa�on -‐ h�p://sgec.stanford.edu/

2012 WEBINAR SERIES PART II: TACKLING THE TOUGH TOPICS IN

ETHNOGERIATRICS

Sponsored by Stanford Geriatric Educa�on Center in conjunc�on with American Geriatrics Society, California Area Health Educa�on Centers,

& Na�vidad Medical Center

Please visit our website for more informa�on -‐ h�p://sgec.stanford.edu/

Carmel Bitondo Dyer, MD Director of Geriatric Medicine, The University of Texas Medical School at Houston Roy M. and Phyllis

Gough Huffington Chair in Gerontology David V. Flores, PhD, LMSW, MPH

Assistant Professor, University of Texas Medical School Houston Associate Director of Clinical Administra�on for the Texas Elder Abuse and Mistreatment Ins�tute

Jason Burne�, PhD Assistant Professor, University of Texas Medial School Houston

Associate Director of Clinical and Behavioral Research for Texas Elder Abuse and Mistreatment Ins�tute

Oct 11 2012

This project is/was supported by funds from the Bureau of Health Professions (BHPr), Health Resources and Services Administra�on (HRSA), Department of Health and Human Services (DHHS) under UB4HP19049, grant �tle: Geriatric Educa�on Centers,

total award amount: $384,525. This informa�on or content and conclusions are those of the author and should not be construed as the official posi�on or policy of, nor should any endorsements be inferred by the BHPr, HRSA, DHHS or the U.S. Government.

WHY CULTURE MATTERS IN CASES OF ELDER MISTREATMENT AND

SELF-‐NEGLECT



“Why Culture Matters in Cases of Elder Mistreatment and Self-neglect” Natividad Medical Center CME Committee Planner Disclosure Statements:

The following members of the CME Committee have indicated they have no conflicts of interest to disclose to the learners: Kathryn Rios, M.D.; Janet Bruman; Tami Robertson; Christina Mourad and Nobi Riley

Stanford Geriatric Education Center Webinar Series Planner Disclosure Statements:

The following members of the Stanford Geriatric Education Center Webinar Series Committee have indicated they have no conflicts of interest to disclose to the learners: Gwen Yeo, Ph.D. and Kala M. Mehta, DSc, MPH

Faculty Disclosure Statement:

As part of our commercial guidelines, we are required to disclose if faculty have any affiliations or financial arrangements with any corporate organization relating to this presentation. Our speakers have indicated they have no conflicts of interest to disclose to the learners, relative to this topic. They will inform you if they discuss anything off-label or currently under scientific research.

About the Presenters Dr. Carmel Bitondo Dyer is a graduate of Baylor College of Medicine, where she completed her Internal Medicine residency and Geriatrics Fellowship. She founded the geriatrics program at the Harris County Hospital District and the Texas Elder Abuse and Mistreatment Ins�tute. Her research and publica�ons have been in the area of elder mistreatment. She was a delegate to the 2005 White House Conference on Aging and has twice provided tes�mony at the U.S. Senate on behalf of vulnerable elders. She has received na�onal and local recogni�on for her teaching abili�es, research in elder abuse and neglect, and dedica�on to the health care of older persons. Dr. Dyer is currently Chief of Staff at LBJ Hospital, Associate Dean for Harris County Programs, and Professor and Director of the Division of Geriatric and Pallia�ve Medicine at The University of Texas Medical School at Houston. Dr. Dyer is the co-‐founder and Execu�ve Director of the Consor�um on Aging and is the current holder of the Roy M. and Phyllis Gough Huffington Endowed Chair in Gerontology.

About the Presenters Dr. Jason Burne� earned his PhD in Health Promo�on and Behavioral Sciences from the University of Texas School of Public Health in Houston Texas. His research career has been dedicated to vulnerable older adults; specifically elder self-‐neglect. He has published over 20 ar�cles on the topic of elder self-‐neglect. Currently, Dr. Burne� is an Assistant Professor in the Department of Geriatric and Pallia�ve Medicine at University of Texas Medical School in Houston and an Adjunct Assistant Professor at the University of Texas School of Public Health in Houston. He also serves as the Associate Director of Clinical and Behavioral Research for the Texas Elder Abuse and Mistreatment Ins�tute (TEAM).



About the Presenters David V. Flores is currently Assistant Professor at the University of Texas Medical School at Houston and has recently been appointed as Associate Director of Clinical Administra�on for the Texas Elder Abuse and Mistreatment Ins�tute (TEAM). Dr. Flores also has a research appointment at the Center for Drug and Social Policy Research at the University of Houston. He received his Doctorate and Masters in Social Work from the University of Houston’s Graduate College of Social Work, a Masters of Public Health with a focus on “Health promo�ons and Behavioral Science” from the University of Texas Health Science Center’s School of Public Health, and is a ASWB Licensed Masters Social Worker. Dr. Flores’s primary research is focused on health dispari�es among underserved aging minority popula�ons and health issues over the life course.

“Why Culture Matters in Cases of Elder Mistreatment and Self-neglect”

Carmel Bitondo Dyer, MD David V. Flores PhD, LMSW, MPH

Jason Burne�, PhD

The University of Texas, Harris Health System and the TEAM Ins�tute

Outline

1.) Introduc�on to Elder Mistreatment and Self-‐Neglect 2.) A World Apart: Cultural and Perceptual Differences in

Elder Mistreatment and Self-‐neglect 3.) Screening Tools and Culture: Results of Latent Class

Analysis



CASE STUDY

�  68 year old Spanish-‐speaking woman �  Claims physical abuse � MMSE 19/30 �  Interview with son �  Full examina�on �  Skeletal survey �  Outcome

HOW SERIOUS IS THE PUBLIC HEALTH PROBLEM?

…



REASON FOR REFERRAL N=527

�  Medical evalua�on needed 189 (36) �  Cogni�ve problems 114 (21.6) �  Unsafe environment 106 (21) �  “Self-‐neglect” 101 (19.2) �  Ques�onable medica�on compliance 75 (14.2) �  Capacity evalua�on 66 (13) �  Poor hygiene 47 (9) �  Lack of u�li�es 38 (7) �  In need of hired caregiver 33 (6.3) �  Falls and mobility problems 21 (4)

TYPES OF MISTREATMENT

�  Caregiver neglect

�  Financial exploita�on

�  Physical abuse

�  Psychological abuse



FINANCIAL EXPLOITATION

CMTC

TYPES OF MISTREATMENT

� Self-‐neglect



Dyer et al.., 2007

LACHS ET AL ELDER MISTREATMENT IS LETHAL



Mortality JAMA August 5, 1998

Status n Deaths %

Self-neglect 180 73 40.3% Elder mistreatment 78 31 53.2%

No EAM 6649 1303 17.3%

DONG ET AL CHAPS COHORT AND APS REPORTS

CHAPS

�  Prospec�ve, popula�on-‐based cohort study �  1993 to 2005 �  Chicago Health and Aging Project (CHAP; a longitudinal, popula�on-‐based, epidemiological study of residents aged > or = 65 years).

�  suspected elder self-‐neglect or abuse reported to social services agencies.



CHAPS: Outcomes and Results

�  Mortality -‐Independent associa�ons of self-‐neglect repor�ng with the risk of all-‐cause mortality

�  RESULTS: 9318 CHAP par�cipants, 1544 reported for elder self-‐neglect

�  Followed up for a median of 6.9 years �  Elder SN was associated with significantly increased risk of 1-‐year mortality.

WHY NOT APPLY THE GERIATRIC APPROACH TO ELDERS REPORTED FOR SELF-‐NEGLECT?

GERIATRIC ASSESSMENT �  1.) Cogni�on �  2.) Mood �  3.) Pharmacotherapy �  4.) Func�onal ability �  5.) Real social history �  6.) History and physical examina�on



PURPOSE OF INTERDISCIPLINARY ASSESSMENT

�  Detect occult disease: demen�a, depression �  Evaluate func�onal level �  Ac�vely rule out problems with medica�on �  Take a holis�c approach to the elder’s living situa�on �  Develop an interdisciplinary care plan

TTEEAAMM

SPECIAL THANKS

�  Adult Protec�ve Service – Both State And Local Regional Staff And Leadership

�  Members of the TEAM Ins�tute

�  The Harris County Hospital District



A World Apart: Cultural and Perceptual

Differences of Elder Abuse and Mistreatment

Outline 1.  Determinants of cultural influences 2.  Cultural, racial, and ethnic homogeneity 3.  Dimensions of culture across the landscape 4.  Accultura�on assimila�on and cultural iden�ty 5.  Transgenera�onal determinants 6.  The role of cultural values 7.  Lost in transla�on 8.  Cultural risk and protec�ve factors 9.  Sugges�ons for a�ending to cultural issues



Culture “The integrated pa�ern of human knowledge, belief, and behavior that depends upon the capacity for learning and

transmi�ng knowledge to succeeding genera�ons.”

“The customary beliefs, social forms, and material traits of a racial, religious, or social group; also: the characteris�c features

of everyday existence shared by people in a place or �me” e.g., Southern culture, drug culture, 70’s culture, The great

depression culture of the 1920s.” Webster’s online, 2012

Number of Persons 65+ in the U.S.

0

10

20

30

40

50

60

70

80

1900 1920 1940 1960 1980 1990 2000 2010 2020 2030

Source: A Profile of Older Americans: 2010, Administration on Aging, DHHS

Future Growth of the Older Minority Popula�on

�  Minority popula�ons ◦  5.7 million in 2000 (16.3% of the elderly popula�on) ◦  8.0 million in 2010 (20.1% of the elderly) ◦  12.9 million in 2020 (23.6% of the elderly)

�  Between 2010 and 2030 popula�ons 65+ ◦  Whites 59% compared with 160% for older minori�es ◦  Hispanics (202%) ◦  African-‐Americans (114%), ◦  American Indians, Eskimos, and Aleuts (145%) ◦  Asians and Pacific Islanders (145%).

Source: A Profile of Older Americans: 2010, Administration on Aging, DHHS



2050 Projected Popula�on Growth by Race

CensusYear

Total Population -

All Ages

Total - All Persons 65 and older

Hispanic Persons 65 and older

Non-Hispanic White

Persons 65 and older

Non-Hispanic Black


Non-Hispanic American

Indians and Alaskan Native


Non-Hispanic Asian


Non-Hispanic Native

Hawaiian and Pacific

Islander Persons 65 and older

Non-Hispanic Persons 65 and older

with Two or More Races

2000 282,158,336 35,107,491 1,756,846 29,394,669 2,818,102 127,737 816,312 19,809 174,0162010 310,232,863 40,228,712 2,857,619 32,243,428 3,322,859 200,323 1,318,961 33,235 252,2872020 341,386,665 54,804,470 5,019,205 41,666,656 4,897,772 337,653 2,408,327 59,532 415,3252030 373,503,674 72,091,915 8,631,108 51,333,789 7,093,697 491,627 3,829,320 95,544 616,8302040 405,655,295 81,238,391 13,150,205 52,468,863 8,493,937 565,905 5,641,586 131,542 786,3532050 439,010,253 88,546,973 17,514,734 51,771,738 9,942,696 645,537 7,434,131 170,040 1,068,097

Sources:

File: 2008 National Population Projections Population Division, U.S. Census BureauRelease date: August 14, 2008

This table was compiled by the U.S. Administration on Aging using the Census data noted.

NP2008_D1: Projected Population by Single Year of Age, Sex, Race, and Hispanic Origin for the United States: July 1, 2000 to July 1, 2050

CHARACTERISTICS OF VALIDATED APS VICTIMS IN COMPLETED IN-‐HOME INVESTIGATIONS FISCAL YEAR 2011

Source: Texas Department of Family and Protective Services 2011

Validated APS

Victims Female Percent of

Total Male Percent of Total Unknown Percent

of Total Race/

Ethnicity Percent of Total

Anglo 17,719 30.5% 11,653 20.1% 34 0.1% 29,406 50.6%

African American 8,548 14.7% 4,933 8.5% 15 0.0% 13,496 23.2%

Hispanic 7,603 13.1% 5,685 9.8% 12 0.0% 13,300 22.9%

Native American 89 0.2% 72 0.1% 0 0.0% 161 0.3%

Asian 183 0.3% 120 0.2% 0 0.0% 303 0.5%

Other 850 1.5% 545 0.9% 7 0.0% 1,402 2.4%

Total 34,992 60.3% 23,008 39.6% 68 0.1% 58,068 100%

Includes disabled, incidence rate of maltreatment for Texas12.4 per 1000

In-Home Validated Victims in Completed Investigations Fiscal Year 2011

Characteristic Total Percentage

Disabled 29,247 50.4%

Aged 28,821 49.6%

Total 58,068 100%

Characteristic Total Percentage

Female 34,99 60.3%

Male 23,008 39.6%

Unknown 68 0.1%

Total 58,068 100%




Perpetrator Characteris�c: Age

Age Female Percent of Total Male Percent of Total

Unknown

Percent of Total

Race/ Ethnicity

Percent of Total

Under 18 181 3.4% 177 3.3% 1 0.0% 359 6.7% 18-‐25 236 4.4% 227 4.3% 0 0.0% 463 8.7% 26-‐35 370 6.9% 369 6.9% 0 0.0% 739 13.9%

36-‐45 545 10.2% 493 9.2% 5 0.1% 1,043 19.6%

Over 45 1,331 24.9% 1,386 26.0% 3 0.1% 2,720 51.0%

Unknown 4 0.1% 4 0.1% 3 0.1% 11 0.2%


Perpetrator Characteris�c: Race/Ethnicity

Race/Ethnicity Female Percent of Total Male Percent of

Total Unknown Percent of Total

Race/ Ethnicity

Percent of Total

Anglo 1,251 23.4% 1,329 24.9% 2 0.0% 2,582 48.4%

African American 512 9.6% 410 7.7% 1 0.0% 923 17.3%

Hispanic 714 13.4% 758 14.2% 2 0.0% 1,474 27.6%

Native American 4 0.1% 2 0.0% 0 0.0% 6 0.1%

Asian 8 0.1% 8 0.1% 0 0.0% 16 0.3%

Other 178 3.3% 149 2.8% 7 0.1% 334 6.3%


Cultural Racial and Ethnic Homogeneity Mispercep�ons

�  Hispanic �  Jewish �  African American �  Muslim �  Asian



Dimensions of Culture and Abuse Across the Landscape

Na�ve Americans Smyer and Clark 2011

Arab Pa�erson et al., 2006 Israeli Kosberg et al., 2003 Japanese Pa�erson et al, 2006, Levesque et al., 2002

Hispanic Deliema et al., 2012

African American Horsford et al., 2011 Chinese Dong et al., 2007, Tam et al, 2006

Korean Lee et al., 2011

Prac��oners, authori�es, and researchers must become aware of cultural reali�es and meanings assigned to forms of adversity. Our assessment and defini�on of poten�al abuse, mistreatment, or self-‐neglect may not correspond with that of the clients’ cultural expecta�ons and cultural experiences.

Sanchez, 1996

Cultural Value Dimensions Impac�ng Elder Mistreatment �  Individualism/Collec�vism Sherman et al., 2008

�  Self-‐construal: “a constella�on of thoughts, feelings, and ac�ons concerning one’s rela�onship to others and the self as dis�nct from others.” Singelis 1994

�  Independent and Interdependent Self-‐construal ◦  Independent (individualis�c) ◦  Interdependent (collec�vis�c) Markus and Kitayama, 1991; Lee et

al., 2012



Determinants of Cultural Influences on Elder Abuse, Mistreatment, and Self-‐Neglect

�  Cultural and ethnic homogeneity misperceived �  Immigra�on status and an�-‐immigra�on climate �  Accultura�on, assimila�on and cultural Iden�ty �  Tradi�onal cultural values �  Gender �  Cultural expecta�ons and prior cultural experiences �  Transgenera�onal effects

Accultura�on, Assimila�on, and Cultural Iden�ty

�  Accultura�on �  Assimila�on �  Country of origin oriented vs. American oriented �  Lack of Cultural Group Reference �  Loss of Social Support Network

Transgenera�onal Determinants �  Mul�genera�onal households �  Language Barrier �  Immigra�on Status �  The Community Broker �  Dependency leads to isola�on



The Role of Cultural Values as Determinants of Elder Abuse or Mistreatment �  Familism ◦  Familismo ◦  Filial Piety

�  Paternalism ◦  Tradi�onal Patriarchal Households ◦ Machismo

Lost in Transla�on

�  Language �  Cultural expecta�ons �  Juxtaposi�on of cultures �  Elder distrust of ins�tu�ons

Factors Contribu�ng to Abuse, Neglect, and Exploita�on: �  Rapidly older adult popula�on Growth �  Alcohol and drug dependency �  Poverty �  Lack of affordable housing and high costs of u�lity bills �  Inadequate access to health care and costly medica�ons �  Toxic family rela�onships �  Dependence of family or others on the income of older

adults �  Violence as a coping mechanism in society �  Physical and mental stress of Denial of benefits, such as SSI and Medicaid, to some

immigrants




Cultural Associated Risk Factors

  Historical segrega�on and an�-‐immigra�on climate   Healthcare barriers, discrimina�on, and exclusion   Lack of recogni�on of cultural values or cultural iden�ty   Lack of financial stability   Undocumented immigra�on status   Limited social support network   Limited access to ins�tu�onal support   Nega�ve cultural values and gender roles

Parra-Cardona et al., 2007

Cultural Associated Protec�ve Factors

  Freedom of cultural expression and associa�on   Cultural values and tradi�ons that promote sense of community

  Language   Established social support networks   Posi�ve cultural values and gender roles

Parra-Cardona et al., 2007

Sugges�ons for A�ending to Cultural Issues

�  Iden�fy cultural iden�ty preference �  Iden�fy degree of adherence to/or acceptance of cultural iden�ty of family members

�  Assess for understanding of situa�on �  Ensure cultural needs and expecta�ons are met �  Seek the counsel others knowledgeable of the culture



Assessments and Differen�al Profiles of Elder Mistreatment and Self-‐Neglect

Elder Mistreatment and Self-‐Neglect Screening

�  Psychometrics ◦  No Construct Valida�on Studies (Are we hi�ng the targets and are we doing so reliably?) ◦  No Measurement Invariance Studies (Are we hi�ng the targets and doing so reliably for groups with different characteris�cs?)

�  Unable to conduct broad epidemiologic surveillance studies and therefore, the true prevalence and incidence es�mates of Elder Mistreatment and Self-‐Neglect remain unknown

�  APS agencies across the country are star�ng to re-‐evaluate their assessment tools and processes for iden�fying cases

Study 1: Methods for Construct Validity and Measurement Invariance

§  Confirmatory factor analysis

§  Cross-‐valida�on §  Measurement Invariance

§  Gender §  Race/Ethnicity



Texas APS Client Assessment and Risk Evaluation (CARE) Tool

�  CARE tool = 57 items with 5 Factors �  Factors: ◦  Living Condi�ons ◦  Financial Status ◦  Physical and Medical Status ◦ Mental Status ◦  Social Rela�ons

Specific Aim 1: Construct Validity Results

Model χ² df CFI RMSEA WRMR Baseline 57 Items 5353 1529 0.77 0.026

Final 43 Items 1536 807 0.95 0.015

Removed 14 items 8 Cross Loadings

Social Condi�ons (5 items) Living Condi�ons (2 items) Mental Status (1 item)

3 Low Reliabili�es 3 Non-‐Significant Loadings

Specific Aim 1: Cross-Validation and Reliability

Model Х2 df CFI RMSEA WRMR 1. Unconstrained Loadings & Thresholds

3015 1615 0.95 0.015 2.0

2. Constrained Loadings & Thresholds

2960 1648 0.96 0.014 2.0

Model Comparisons Δ Х2 Δdf ΔCFI ΔRMSEA ΔWRMR DIFFTEST 1 vs. 2 55 33 +0.01 -‐0.001 +0.0 0.69

Baseline Structural and Measurement Model Fit and Cross-‐Valida�on Sta�s�cs for the 5-‐Factor Client Assessment and Risk Evalua�on (CARE) tool

Physical and Medical Status (0.78) Social Connec�on (0.83) Financial Status (0.87) Mental Status (0.89) Living Condi�ons (0.93)



Specific Aim 1a: Measurement Invariance Results

�  Gender Invariance ◦  Par�al Invariance (correlated items) ◦  Drug Use ◦  Ability, Knowledge and Willingness to Care for the Client

�  Ethnicity: Caucasians, African-‐Americans and Hispanics ◦  Unable to use financial status construct in Hispanics due to inadmissible es�mates

Specific Aim 1a: MI Continued

�  Caucasians & African-‐Americans (5 Factors) ◦  Invariant item loadings and thresholds across Caucasian and African-‐American groups except for correlated errors

�  Caucasians & African-‐Americans vs. Hispanics (4 Factors) ◦  Invariant Item-‐Loadings and Thresholds

�  Caucasians, African-‐Americans, Hispanics (4 Factors) ◦  Item-‐loading and threshold invariance except for correlated errors presented above between Caucasians and African-‐Americans

Burne�, 2012

Implications

�  CARE tool ◦  Construct Validity (We are hi�ng our targets and doing so reliably) ◦  Iden�fica�on ◦  Broad Epidemiologic Surveillance ◦  Incidence and Prevalence Es�mates ◦  Measurement Invariance (We are hi�ng the targets equally well

across different groups) ◦  No Health and Social Service Dispari�es ◦  Poten�al for Compara�ve Research



Self-‐Neglect Typologies �  Self-‐Neglect Types ◦  No studies which have determined whether self-‐neglect is a global breakdown of behaviors or whether these behaviors may be restricted to single areas of life

◦  Knowing whether or not different types exist and if so, iden�fying their demographic differences, risk factors and mortality risks could impact triage and interven�ons

LCA: Class Probabilities

Self-‐Neglect (total sample)

Environmental Neglect

Physical and Medical Neglect

Global Neglect

Financial

Financial Status 0.128 0.045 0 0.19 1.00 Living Condi�ons 0.409 0.77 0.087 0.61 0.34 Mental Status 0.335 0 0.28 0.78 0.14 Physical and Medical Status

0.606 0.44 0.62 0.84 0.25

Social Connectedness

0.176 0.053 0.12 0.42 0.04

Latent Class Probabili�es Indica�ng Problems in the 4 Classes based off the Texas APS Client Assessment and Risk Evalua�on (CARE) tool

LCA: Graphical Plot of Latent Elder Self-Neglect Classes

Global Neglect (Caucasians) Financial Neglect (African-‐Americans) Burne�, 2012

§  Probability Plots for 4 Self-Neglect Latent Classes Based on the 5 Domains of the Texas APS Client Assessment and risk Evaluation (CARE) tool

0

0.2

0.4

0.6

0.8

1

1.2

FS LC MS PMS SC

Environmental Neglect (22%) Physical and Medical Neglect (49%) Global Neglect (21%) Financial (9%)



LCA Implications

�  APS Training

�  Risk Factors for different types of elder self-‐neglect

�  Differen�al Mortality Risks

�  Recidivism

LCA Future Studies

�  Why racial/ethnic differences occur between the classes

�  Valida�on in other samples

�  Minimum BIC using other methods

�  Differen�al Mortality Risks, Risk Factors and Recidivism

Overview

�  CARE Tool ◦  Construct Validity ◦  Reliable Constructs ◦  Measurement Invariance for Gender and Racial/Ethnic groups

�  Latent Classes of Elder Self-‐Neglect ◦  4 Classes (Physical and Medical, Environmental, Global, Financial) ◦  Physical and Medical Neglect (50%) ◦  Class differences based on Race/Ethnicity



Innovation �  First Elder Mistreatment and Self-‐Neglect Assessment with supported

Construct Validity and Measurement Invariance ◦  Broad Epidemiologic Surveillance ◦  Improved Incidence and Prevalence Es�mates ◦  Basis for developing a wide-‐spread assessment ◦  Compara�ve Research

�  First to quan�ta�vely iden�fy and characterize dis�nct types of elder self-‐neglect ◦  Risk Factor Studies ◦  Differen�al Mortality Risks ◦  Recidivism

CONCLUDING REMARKS

Q & A �  We now have some �me to answer your

ques�ons. if you have any ques�ons, please use the “Chat” feature located on the right side of your screen. Please send your chat to everyone if possible.

�  A�er the Q and A, We would like to ask each of the par�cipants to answer the short evalua�on ques�onnaire.

Please complete our short survey, We appreciate your feedback. NOTE: Continuing Education Participants must complete a final survey in

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References 1.  Amstadter, A. B., Cisler, J. M., McCauley, J. L., Hernandez, M. A., Muzzy, W., & Acierno, R. (2011). Do incident and

perpetrator charachteris�cs of elder mistreatment differ by gender of the vic�m? Results from the Na�onal Elder Mistreatment study Journal of Elder Abuse and Neglect, 23(1), 43-‐57.

2.  Anme, T., McCall, M., & Tatara, T. (2005). An Exploratory Study of Abuse Among Frail Elders Using Services in a Small Village in Japan. Journal of elder abuse & neglect, 17(2), 1-‐20. doi: 10.1300/J084v17n02_01

3.  Burne� J. (2012) Elder Mistreatment and Self-‐Neglect Among Community-‐Dwelling Older Adults: Studies of Construct Validity, Measurement Invariance and Latent Classes. Published Disserta�on

4.  Cardona, J. R. P., Meyer, E., Schiamberg, L., & Post, L. (2007). Elder Abuse and Neglect in La�no Families: An Ecological and Culturally Relevant Theore�cal Framework for Clinical Prac�ce. [Ar�cle]. Family Process, 46(4), 451-‐470. doi: 10.1111/j.1545-‐5300.2007.00225.x

5.  Dakin, E., & Pearlmu�er, S. (2009). Older women's percep�ons of elder maltreatment and ethical dilemmas in adult protec�on services: A cross-‐cultural exploratory study. Journal of Elder Abuse & Neglect, 21, 15-‐57.

6.  DeLiema, M., Gassoumis, Z. D., Homeier, D. C., & Wilber, K. H. (2012). Determining prevalence and correlates of elder abuse using promotores: low-‐income immigrant La�nos report high rates of abuse and neglect. [Research Support, N.I.H., Extramural]. Journal of the American Geriatrics Society, 60(7), 1333-‐1339. doi: 10.1111/j.1532-‐5415.2012.04025.x

References Cont. 7.  Dong, X., Simon, M. A., Gorbien, M., Percak, J., & Golden, R. (2007). Loneliness in older chinese adults: a risk factor for

elder mistreatment. Journal of the American Geriatrics Society, 55(11), 1831-‐1835. doi: 10.1111/j.1532-‐5415.2007.01429.x

8.  Dyer CB, Goodwin JS, Pace S, Burne� J, & Kelly PA. (2007) Self-‐Neglect Among the Elderly: A Model Based on More than 500 Pa�ents Seen by A Geriatric Medicine Team. American Journal of Public Health. Volume 99, No. 9. 1671-‐1676.

9.  Holkup, P. A., Salois, E. M., Tripp-‐Reimer, T., & Weinert, C. (2007). Drawing on Wisdom From the Past: An Elder Abuse Interven�on With Tribal Communi�es. [Ar�cle]. Gerontologist, 47(2), 248-‐254.

10.  Horsford, S. R., Parra-‐Cordona, J. R., Post, L. A., & Shiamberg, L. (2011). Elder abuse and neglect in African American families; Informing prac�ce based on ecological and cultural frameworks. Journal of Elder Abuse & Neglect, 23(1), 75-‐88.

11.  Kosberg, J. I., Lowenstein, A., Garcia, J. L., & Biggs, S. (2003). Study of elder abuse within diverse cultures. Journal of elder abuse & neglect, 15(3/4), 71-‐89.

12.  Lee, H. Y., & Eaton, C. K. (2009). Financial abuse in elderly Korean immigrants: mixed analysis of the role of culture on percep�on and help-‐seeking inten�on. [Research Support, Non-‐U.S. Gov't]. Journal of Gerontological Social Work, 52(5), 463-‐488. doi: 10.1080/01634370902983138

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