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Awareness and Answers for the Public Health Concern of

Violence in Older Adults: An Introduction to Special Issue

Ashley Stripling, Natalie Dautovich

PII: S1359-1789(20)30238-X
DOI: https://doi.org/10.1016/j.avb.2020.101534
Reference: AVB 101534

To appear in: Aggression and Violent Behavior

Please cite this article as: A. Stripling and N. Dautovich, Awareness and Answers for the
Public Health Concern of Violence in Older Adults: An Introduction to Special Issue,
Aggression and Violent Behavior (2020), https://doi.org/10.1016/j.avb.2020.101534

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Awareness and Answers for the Public Health Concern of Violence in Older Adults: An
Introduction to Special Issue
Ashley Stripling, Ph.D. & Natalie Dautovich, Ph.D.
Nova Southeastern University, Department of Clinical and School Psychology

Abstract
The United States is in the midst of unprecedented demographic change, as the nation

increases in age as well as racial and ethnic pluralism (Vespa, Armstrong, & Medina, 2020). As

the nation ages and grows more diverse, violence among older adults has been identified as a

public health problem (CDC, 2020). As we look toward the demographic turning points projected

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to occur in the upcoming decades, we are poised to make a real and lasting impact to public

health crises, such as violence among older adults, including among racial and ethnically diverse

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elders. With this in mind, this introduction to the special issue on Violence in Older Adults

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defines and discusses the seriousness of violence in late life, and outlines the key areas covered
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including (1) unique factors contributing to aggression and violence in late-life, (2) the

perpetration of violence by older adults, (3) assessments and interventions for older adults, and
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(4) the importance of representation and social context. We close by identifying how the
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introduction of new public health problem, the COVID-19 pandemic, may impact violence in

late-life and summarize important areas for future research and policy.
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Since 2011 when the first Baby Boomers reached 65 years old, the United States’ elder

population has grown by over a third and is projected to continue to increase (U.S. Census

Bureau, 2020). As the nation ages and grows more diverse, violence among older adults has been

identified as a public health problem (CDC, 2020). Violence commonly impacts older adults,

either by being directed toward (elder abuse and intimate partner violence), self-directed

(suicide), or by being perpetuated by elders (intimate partner violence and violence by those

living with neurocognitive disorders), however is often perceived to be a problem of the young

(Rosen, Makaroun, Conwell, & Betz, 2019). This special issue of Aggression and Violent
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Behavior was developed to raise awareness about these topics and to inform research, policy, and

practice.

Given the seriousness of the problem of violence in late-life in the United States, as well as

the documented consequences and barriers to prevention/treatment, we asked researchers and

scholars to explore violence in aging, with an emphasis on intersections of identity and an eye

towards the impact of violence on other late-life concerns. In response, eleven papers that

successfully completed peer review addressed key areas including (1) unique factors contributing

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to aggression and violence in late-life, (2) the perpetration of violence by older adults, (3)

assessments and interventions for older adults, and (4) the importance of representation and social

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context.

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Unique Factors Contributing to Aggression and Violence in Late-Life
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Although older adults may be included in general research on violence and aggression,

without examining age differences in risk and protective factors, and without designing studies
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with a developmental focus, we miss understanding the unique factors that change and emerge
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with age. Three papers in this special issue consider factors contributing to aggression and

violence in late-life from a developmental lens.

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One factor prevalent among older adults is chronic pain, with up to ½ of all older adults
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experiencing chronic pain. Furthermore, chronic pain is an urgent community issue as it increases

risk for multiple adverse outcomes including depression, disability, and suicide among older

adults. The Maccarrone et al. (2020) systematic review in this special issue investigates trauma

and PTSD symptoms as risk factors for chronic pain that have been understudied in the older

adult population. The authors identify a significant link between cumulative trauma, lifetime

trauma, and combined adverse childhood evens and chronic pain in older adults. However, given

the paucity of articles (10 met inclusion criteria) and the added complexity of comorbidity in

older adulthood, the authors suggest further research in this area is required.
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As the Maccarrone et al. (2020) review noted, older adults often experience the added burden

of a cumulation of trauma across their lifespan. Nuccio & Stripling (2020) explicitly examined

this trauma cumulation in their systematic view of polyvictimization – sequential or concurrent

occurrences of trauma – in older adults. Furthermore, the authors reviewed existing literature

examining the positive outcomes of resilience and post-traumatic growth in relation to late-life

polyvictimization and PTSD. Although existing literature is sparse, and findings are mixed, there

is support for the applicability of the Resilience Portfolio Model framework in late-life and for

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understanding the development of resiliency post-trauma in older adults. This research makes a

valuable contribution to the literature by highlighting the importance of a strengths-based

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approach to examining older adult survivorship in late-life.

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Lastly, an important contributor to violence and aggression experienced by and perpetrated
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by older adults is serious mental illness. Schloss & Davidtz’s (2020) review of this topic within

older adults is timely given that the aging of the population and increasing life expectancy means:
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(1) more older adults will be living with serious mental illness and/or (2) more older adults will
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be providing care for someone with mental illness. The authors report a limited number of studies

addressing serious mental illness in older adults and limitations among these studies that preclude
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consensus such as underreporting, a lack of agreement on an age criterion for “older adulthood”,
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and varying definitions of violent and aggressive behavior. Clearly this is an area that is in need

of further attention in the coming years.

Perpetration of Violence by Older Adults

Beyond considering older adults as victims of violence, two papers in the special issue

examine violence perpetrated by older adults. The first, an empirical study by Dautovich et al.

(2020a) assesses sleep quality as a predictor of aggression and identifies psychosocial

mechanisms underlying this association. Although understudied in older adults, sleep, as a

universal, daily behavior, can have a profound impact on the ability to inhibit aggressive

tendencies. The authors found that poorer sleep quality is linked to the greater expression of anger
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outwards. Furthermore, the pathways of this association appear to be emotional (poorer sleep

leads to angrier affect) and cognitive (poorer sleep leads to negative perceptions of relationships).

Interestingly, for older adults, the sleep—anger expression association was primarily driven by

negative perceptions of their relationship with their spouse or partner. These findings are

important given that approximately 10% of older adults report intimate partner violence and this

is likely an underestimation of the actual occurrence (Schreiber & Salivar, 2020). Consequently,

sleep interventions such as cognitive behavioral therapy for insomnia (CBTi) which are endorsed

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by the American College of Physicians as a first-line treatment for older adults (Qaseem et al.,

2016) may be a potential intervention point to prevent the perpetration of violence in late-life.

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The second paper in this special issue to address violence perpetrated by older adults is the

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Scheriber & Salivar (2020) systematic review identifying risk factors for intimate partner
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violence in older adults and the examining the applicability of the Vulnerability Stress Adaptation

model to understand this late-life violence. The authors identify prevalent risk factors for intimate
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partner violence in late-life including cognitive impairment or dementia, social isolation, physical
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impairment, depressive symptoms, and risks involving the caregiver. Furthermore, the authors

found utility in using the Vulnerability Stress Adaptation model for understanding how older
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adults may bring vulnerabilities into their marriage (e.g., personality traits), then encounter stress
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(e.g., financial strain), and then engage in adaptation to these stressors that may be helpful or

maladaptive (e.g., developing insomnia in response to stress). This review provides a helpful

framework for understanding the development of intimate partner violence and identifying

intervention targets in late-life.

Assessment and Interventions for Older Adults – Broadly Considered

In addition to understanding risk factors and consequences of violence in late-life, it is

necessary to have age-appropriate assessment and interventions in this age group. Ravyts et al.

(2020) in the special issue identify five scales and five subscales for assessing aggression in older

adults. Although the scales have adequate reliability and validity (subscales to a lesser degree),
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the authors note significant limitations in that they are predominately observational and limited to

individuals with dementia or living in a long-term care setting. The authors suggest that future

research is to needed to develop self-report scales that would be appropriate for community-

dwelling older adults and measures that are predictive of aggressive behaviors.

The Burnes et al. (2020) paper in the special issue helps to guide future intervention work for

aggression in older adults by identifying key outcomes for elder abuse intervention studies.

Burnes et al. (2020) comment on the increasing incidence of elder abuse and the consequent

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overloading of community-based elder abuse response programs such as Adult Protective

Services. They suggest that to effectively move the intervention field forward, changes in

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intervention targets are needed such as focusing on: eco-systematic factors not just the victim,

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mediator/moderator factors in the intervention process, and qualitative research to assess
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stakeholders’ priority outcomes. Furthermore, the development of a common measure of elder

abuse intervention outcomes would facilitate comparison across studies (e.g., Minimum Data Set
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for nursing homes).

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Importance of Representation and Social Context

Lastly, we are pleased and encouraged by the large portion of papers in this special issue that
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take a diverse, equitable, and inclusive approach to understanding aggression and violence in late-
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life. These papers highlight the increasing diversity of our aging population and reinforce the

importance of considering the broader socioecological context. Shepherd & Brochu (2020)

identify the stereotypes of older adults as “warm but not competent” and “pitied and sometimes

admired” which leads to older adults being “sometimes helped, sometimes excluded.” As a result

of these stereotypes, the authors identify older adults as at risk for passive harm by family,

strangers, institutions, and society. Furthermore, if older adults don’t fit the stereotype of “warm,”

they can become victims of active harm. By identifying common stereotypes about older adults

and situating these stereotypes in a societal context, the authors draw attention to factors

potentially contributing to the rise in elder abuse and provided opportunities for intervention.
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Roberto & Hoyt (2020) provide a novel review of research on the abuse of older women by

moving beyond a traditional gender difference approach to focus on the actual experiences of

older women that are not masked in comparative analyses to men. The authors included articles

with samples comprised only of women or where women comprised 50% or more of the sample.

Based on their review, the authors note that the majority of research on the abuse of older women

focuses on White women without inclusion of underrepresented older adults or consideration of

the intersections of multiple social locations. Additionally, existing research focuses on gender

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differences rather than the lived experiences of women and neglects to identify abuser

characteristics. Further research is needed to address these concerns and identify the less tangible

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long-term consequences of elder abuse for older women.

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Hincapie et al. (2020) raise important concerns about how to assess and treat elder abuse
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among Latinx older adults. Given the rapid growth of the Latinx older population and their

unique cultural experiences, there is an urgent need to understand the adequacy and relevance of
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existing elder abuse assessments and interventions for this population. The authors identify only
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one assessment, the WC-RAPS (Ramirez et al., 2019), that is normed on Spanish speaking Latinx

in the United States. A greater number of interventions were identified; however, the review
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reveals limited cultural competence across agencies, organizations, and community-based

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programs due in part to few Spanish speaking providers and high work demands. Importantly, the

unique strengths and risk factors for Latinx older adults are identified including familism,

vergüenza, concerns about legal status and sharing finances, hesitations to report abuse, and lack

of awareness of elder abuse laws. Therefore, both assessment and interventions for elder abuse in

Latinx elders need to have increased cultural competency and address culturally-specific barriers

and strengths within this community.

Lastly, the paper by Dautovich et al. (2020) examines suicidality among older adults from an

intersectional perspective. The authors note that the higher rates of suicide observed in middle-

age will soon be seen in late-life as the middle-aged cohort moves into older adulthood.
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Furthermore, diverse older adults are comprising an increasingly larger segment of the population

with a projected proportion of 34% by 2040. Hence, there’s a need to understand risk and

protective factors for suicide in older adults with diverse, interesting identities. Unfortunately,

existing suicide prevalence data within the United States is limited by identifiers that are broad

and mask many aspects of identity. Furthermore, the majority of research on risk and protective

factors for suicide in older adults has focused on White elders. The authors counter this approach

by reviewing existing literature on psychosocial, physical, mental health, and functioning risk and

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protective factors specific to different races, ethnicities, gender identities, sexual orientation,

geographic locations, and the intersection of multiple identities. The authors end with an

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overview of culturally responsive prevention or interventions that discusses “compatibility

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heuristics” (Rogers & Russell, 2014) between the client and the clinician that could serve as
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barriers to intervention as well as the limited amount of culturally-specific suicide assessments

(e.g. one by Chu, 2013).

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Moving Forward
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As this project was coming to competition, the United States was impacted by the global

COVID-19 pandemic, which, along with its associated disease, is particular deleterious for older
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adults. Outside of the biological and psychological impact of the novel coronavirus, the
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subsequent public health restrictions (i.e., stay-at home orders, isolation, quarantine,

disconnection from support and community resources) and the associated economic impact have

been identified as risk factors for increased self and family violence, in late-life including elder

abuse and elder intimate partner violence. Although the true extent of the damage caused by this

pandemic to the United States’ elder population may remain unknown for some time, due to

barriers to reporting and other co-occurring public health crises, it is the hope of the authors that

this special issue will provide foundational knowledge to bring awareness thus guiding future

funding and public policy to help all Americans age well.

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Taken together, the authors in this special issue highlight the need for further research on

aggression and violence in late-life among diverse groups of older adults. A major contribution of

this special issue is the recognition that aggression and violence in older adults occurs within the

context of multiple systems, many of which are inequitable and oppressive. Therefore, a focus

solely on individual pathology is limiting our scope for understanding the full development of,

and intervention approaches for, violence in late-life.

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