Association Between Different Forms of Elder Mistreatment and Cognitive Change

Abstract

Objectives: Elder mistreatment (EM) is associated with worse physical health and psychological well-being, but little is known regarding its cognitive consequences. Methods: Data were derived from the T1–T2 PINE (n = 2713). EM was measured by psychological, physical, and sexual mistreatment; financial exploitation; and caregiver neglect. Cognitive function was evaluated by global cognition, episodic memory, working memory, processing speed, and Mini-Mental State Examination. Linear regression was used. Results: At baseline, physical mistreatment and caregiver neglect were associated with lower global cognition and cognitive domains, while psychological mistreatment was associated with higher cognitive function. Older adults with incident psychological mistreatment, physical mistreatment, and caregiver neglect had a faster decrease in global cognition and cognitive domains over 2 years. Discussion: This study is among the first to examine the association between different forms of EM and cognitive change. These findings provide a basis for engaging ethnic minorities with EM to maintain cognitive health.

Keywords

elder mistreatment cognitive function longitudinal study Chinese

Introduction

The National Research Council defines elder mistreatment (EM) as “(a) intentional actions that cause harm or create a serious risk of harm (whether or not harm is intended) to a vulnerable elder by a caregiver or other person who stands in a trust relationship to the elder or (b) failure by a caregiver to satisfy the elder’s basic needs or to protect the elder from harm” (National Research Council, 2003). Five subtypes of EM are generally recognized by researchers, health practitioners, and legal statutes: psychological mistreatment, physical mistreatment, sexual mistreatment, financial exploitation, and caregiver neglect (Dong et al., 2014, Dong, 2017). According to the definition by the National Center on Elder Abuse, psychological mistreatment involves “inflicting mental pain, anguish, or distress on a person.” Physical mistreatment is defined as “intentional use of physical force that results in illness, injury, pain, or functional impairment.” Sexual mistreatment is “nonconsensual sexual contact of any kind.” Financial exploitation is “misappropriation of an older person’s money or property” (National Center on Elder Abuse, 2020). Caregiver neglect is failure by a caregiver to provide an older adult with life’s necessities, these needs being defined by activities and instrumental activities of daily living (ADL) (Burnes et al., 2015).

EM was associated with increased rates of hospital admissions and institutionalization, and resulted in a higher mortality rate (Dong et al., 2009; Dong & Simon, 2013; Li et al., 2019c), while less is known regarding its cognitive consequences. A few studies investigated EM and cognition through analyzing Adult Protective Services (APS) data (DeLiema, 2017; Wood et al., 2014). However, older adults with EM may choose to hide their mistreatment rather than report it to APS for fear of the consequences and stay in an abusive situation (VandeWeerd et al., 2006). EM reported to APS represents the “tip of iceberg” phenomenon which drastically underestimates the scope of EM in community population settings (Friedman et al., 2014). A national study showed that over five times as many new incidents of abuse and neglect were unreported than those that were reported to APS (National Center on Elder Abuse, 1998).

EM and Cognitive Function

Cognitive impairment was regarded as a risk factor leading to EM. One study reported that short-term memory problems were associated with potential EM, measured by physical and psychological mistreatment and neglect, among older adults seeking home and community-based services in Michigan (Shugarman et al., 2003). A population-based study using matched survey data collected in Chicago and EM cases reported to APS found that the lowest tertiles of global cognition, Mini-Mental State Examination (MMSE), episodic memory, and perceptual speed were associated with increased risk of any types of EM, such as psychological, physical, and sexual mistreatment; financial exploitation; and caregiver neglect, in African American and European Americans (Dong et al., 2011). With a few exceptions, one study reported that cognitive function, measured by memory, knowledge, language, and orientation, was not significantly associated with psychological mistreatment and financial exploitation among older whites, older Blacks, and other ethnic groups in Allegheny County, Pennsylvania (Beach et al., 2010).

In contrast to the relationship between cognitive function and EM, the impact of EM on cognitive function has not been sufficiently investigated. Previous studies either compared the cognitive function between the EM group and the control group, or tested the association between EM and cognitive function while controlling limited demographic confounders (DeLiema, 2017; Wood et al., 2014). However, the cross-sectional research design limited the understanding in the impact of EM on cognitive function.

Mistreatment and Cognitive Function in Childhood and Adulthood

Although less is known regarding the impacts of EM on cognitive aging, the influence of exposure to mistreatment on cognitive development has been well studied in childhood and adulthood. Most studies tested the relationship between overall mistreatment and cognitive function, while only a few studies examined specific forms of mistreatment. Studies of mistreated children showed poor functioning on episodic memory (De Bellis et al., 2013; Vasilevski & Tucker, 2016), working memory (Perna & Kiefner, 2013; Vasilevski & Tucker, 2016), and processing speed (Vasilevski & Tucker, 2016) than the control group. Similarly, exposure to mistreatment during adulthood also deteriorated the cognitive function. Intimate partner violence was significantly associated with decline in attention, visuoperceptual ability, and executive function (Williams et al., 2017). Such findings from childhood and adulthood contexts highlight the importance of exploring the impact of EM on cognitive function among older adults.

Demographic shifts in older populations in the United States call for research and policy to deepen the understanding of the aging experience of minority older adults. According to the estimated number of Asian Americans in 2017, the Chinese population (5.2 million) constitutes the largest segment of the Asian American population (United States Census Bureau, 2017). US Chinese older adults rely heavily on their families due to language and cultural barriers, which put them at a higher risk to experience EM (Dong, 2015; Dong et al., 2017; Li, Chen et al., 2020, Li, Guo et al., 2020; Li & Dong, 2018a; Li et al., 2019b). The purpose of the present study was to add to this growing body of knowledge by addressing the relationship between EM and cognitive change with two-wave panel data among US Chinese older adults. Specifically, we tested the following hypotheses:

Older adults with any subtype of EM (psychological, physical, and sexual mistreatment; financial exploitation; and caregiver neglect) at T1 have poor performance in T1 global cognition and cognitive domains than those without EM.

Older adults with any subtype of EM at T1 and/or T2 experience a faster decline in global cognition and cognitive domains over 2 years than those without EM at both waves.

Methods

Sample

Data were derived from the PINE study, a community-engaged, population-based epidemiological study of U.S. older Chinese immigrants aged 60 years and above in the greater Chicago area (Dong, 2014). Participants were self-reported as Chinese, and the baseline cohort was 3157 from 2011–2013; follow-up interviews were conducted with 2713 participants from 2013 to 2015. Face-to-face home interviews were conducted by trained multicultural and multilingual interviewers. The working sample consisted of 2713 participants who finished the two-wave interview. The study was approved by the Institutional Review Board at Rush University Medical Center in Chicago, Illinois. Written informed consent was obtained from all participants.

Measures

Cognitive Function

In the present study, we used a validated Chinese version of MMSE (Folstein et al., 1975), immediate recall, and delayed recall of the East Boston Story Test (Albert et al., 1991), the Digit Span Backwards assessment from the Wechsler Memory Scale-Revised (DB) (Wechsler, 1987), and the oral version of the 11-item Symbol Digit Modalities Test (SDMT) (Smith, 1982) to assess cognitive function. The raw scores from the five tests were converted to Z scores and averaged to yield a global cognition (Li & Dong, 2018b; Li, Chen, et al., 2020, Li, Guo et al., 2020).

In the East Boston Story Test, the interviewer will read a brief story containing three short sentences, each of which contains two ideas. In the immediate recall of the East Boston Story Test, participants were asked to repeat as much of the story as they could remember right after its presentation. In the delayed recall of the East Boston Story Test, participants were asked to recall the story again after a distracting task of approximately 2 minutes duration. We converted raw scores on immediate recall and delayed recall of the East Boston Memory Test to Z scores and averaging the Z scores to get the domain score for episodic memory. This way to measure and construct cognitive domains has been widely used in previous research (DiNapoli et al., 2014; Wilson et al., 2005). The DB remains the prevalent approach to evaluate working memory by asking participants to repeat 12 groups of numbers backwards. The total number of correct answers is their score for DB. The SDMT was used to test the processing speed, which requires visual scanning and tracking, and motor speed. The SDMT has a key at the top of the page with numbers and symbols. Participants were asked to identify the correct number for each corresponding symbol during the 90 seconds of the test. The total number of correct answers is their score for the SDMT. We used the continuous measure of global cognition, MMSE, episodic memory, working memory, and processing speed, instead of a dichotomous variable, which allowed us to test the spectrum of cognitive function with greater statistical power. Cognitive change was using T2 minus T1 cognition.

EM

To protect the privacy of participants and ensure the quality of EM data, the interview was conducted at the participants’ homes without family members nearby. We asked participants whether they experienced any form of EM, including psychological, physical, and sexual mistreatment; financial exploitation; and caregiver neglect, since they turned 60 years.

Psychological mistreatment and physical mistreatment were measured by the modified Conflict Tactics Scale (Straus et al., 1996). Regarding psychological mistreatment, we asked participants “since you turned 60 years, have any of your family members or anyone else that you trust, or feel close with ever…” (1) screamed or yelled at you, (2) insulted you, called you names, and swore at you, (3) said something to deliberately hurt you, (4) stomped out of room after an argument, (5) destroyed something that belong to you, (6) threatened to hit you or throw something at you, (7) threatened to send you to a nursing home, and (8) threatened to abandon you or stop taking care of you.” Any affirmative response to the eight items was defined as psychological mistreatment. Cronbach’s alpha of psychological mistreatment was .75 in our sample.

In terms of physical mistreatment, we asked participants “since you turned 60 years, have any of your family members or anyone else that you trust ever…” (1) hit or slapped you, (2) pushed or shoved you, (3) shook you, (4) kicked you, (5) handled you roughly in any other way, (6) thrown something at you, (7) twisted your arm or hair, (8) choked you, (9) slammed you against the wall, and (10) beat you up. Any affirmative response to the 10 items was defined as physical mistreatment. Cronbach’s alpha of physical mistreatment was .80.

Financial exploitation was measured by 17 items (Conrad et al., 2009). We asked participants “since you turned 60 years, has anyone ever…” (1) gave poor reasons or refused to give you reasons or lied about how they to spend your money, (2) convinced you to turn the title of your home properties over to them, (3) have there been unexplained disappearances of your money or possessions, (4) became the payee on your benefit check and used the money for themselves, (5) changed the direct deposit destination so as to benefit themselves, (6) has there even been unusual/unauthorized activity in your bank accounts, (7) forced/pressured you to change/sign legal or financial documents, (8) used your money on themselves instead of you, (9) borrowed money and not paid back, (10) said that they were buying something for you, but it was really for their own use, (11) switched some of your expensive items for cheaper ones, (12) tried to prevent you from spending your money in order to maximize the inheritance, (13) felt entitled to use your money for him/herself, (14) overcharged you for work or service that were done poorly or never done, (15) tricked or pressured you into buying something that you now regret buying, (16) make you a victim of fraud, and (17) make you a victim of a scam. Any affirmative response to the 17 items was defined as financial exploitation. Cronbach’s alpha of financial exploitation was .57.

Sexual mistreatment was measured by a one-term question “has anyone ever touched your private areas or your body when you did not want this?” An affirmative “yes” response to this question was defined as sexual mistreatment. A twenty-item unmet needs assessment, including unmet needs in activities and instrumental ADL, was used to evaluate caregiver neglect (Moon et al., 2002). Cronbach’s alpha of caregiver neglect was .78. We divided our participants into four groups based on their exposure to EM during two waves: T1 EM T2 EM, T1 EM T2 no EM, T1 no EM T2 EM, and T1 no EM T2 no EM.

Covariates

Covariates included demographic factors (age and gender), social economic status (education and income), health-related factors (medical comorbidities, physical function, and depressive symptoms), and family and social factors (social support, social strain, living arrangement, network size, and family composition). Physical function was measured by Katz ADL (Dong & Li, 2016; Katz et al., 1970; Li & Dong, 2017). Depressive symptoms were measured by the Patient Health Questionnaire-9 (Li et al., 2019a; Spitzer et al., 1999).

Data Analysis

We used descriptive statistics to report the characteristics of the sample. To test the first hypothesis, we used linear regression to examine the relationship between different forms of EM and global cognition and cognitive domains at baseline while controlling demographic factors, social economic status, health-related factors, and family and social factors. To address the second hypothesis, linear regression was used to test the relationship between different forms of EM and cognitive change (T2-T1) while controlling confounding variables. The missing data were around 5% in our sample, and listwise deletion was used to handle missing data. All statistical analyses were conducted using SAS, version 9.4.

Results

Among the 2713 participants, more than half of them (58.4%) were women. They had an average of 8.7 years of education. At baseline, they had a mean (SD) age of 74.5 (8.1) years (range 61.2–105.7). The majority of them (85.8%) had an annual income of less than US $10,000. The mean of medical comorbidities was 2.1 (SD = 1.5). The mean ADL was .3 (SD = 1.9), ranging from 0 to 24. The mean depressive symptoms were 2.6 (SD = 4.1), ranging from 0 to 27. The mean social support was 6.8 (SD = 3.0), ranging from 0 to 12. The mean social strain was .7 (SD = 1.2), ranging from 0 to 10. An average number of 1.8 co-residents lived with participants. The mean network size with strong ties was 3.3 (SD = 1.5). Older adults had an average number of 8.0 family members. Regarding psychological mistreatment, the subsample sizes for four groups are: T1 yes T2 yes (n = 56), T1 yes T2 no (n = 202), T1 no T2 yes (n = 118), and T1 no T2 no (n = 2322). In terms of physical mistreatment, the subsample sizes are: T1 yes T2 yes (n = 2), T1 yes T2 no (n = 23), T1 no T2 yes (n = 13), and T1 no T2 no (n = 2662). With respect to financial exploitation, the subsample sizes are: T1 yes T2 yes (n = 27), T1 yes T2 no (n = 214), T1 no T2 yes (n = 71), and T1 no T2 no (n = 2380). As for sexual mistreatment, the subsample sizes are: T1 yes T2 yes (n = 1), T1 yes T2 no (n = 5), T1 no T2 yes (n = 3), and T1 no T2 no (n = 2691). Regarding caregiver neglect, the subsample sizes are: T1 yes T2 yes (n = 63), T1 yes T2 no (n = 258), T1 no T2 yes (n = 290), and T1 no T2 no (n = 2099).

Table 1 presents the relationship between EM (psychological, physical, and sexual mistreatment; financial exploitation; and caregiver neglect) and cognitive function (global cognition, episodic memory, working memory, processing speed, and MMSE) at baseline while controlling confounding variables. Older adults with psychological mistreatment were associated with higher global cognition (b = .080, SE = .040, p < .05) and episodic memory (b = .137, SE = .057, p < .05). Older adults with physical mistreatment had lower MMSE (b = −1.449, SE = .713, p < .05). Caregiver neglect was associated with lower global cognition (b = −.226, SE = .036, p < .001), episodic memory (b = −.390, SE = .051, p < .001), working memory (b = −.435, SE = .126, p < .001), and processing speed (b = −2.715, SE = .622, p < .001).

Table 1.

Association Between Subtypes of Elder Mistreatment and Global Cognition and Cognitive Domains at Baseline.

	Global cognition b (SE)	Episodic memory b (SE)	Working memory b (SE)	Processing speed b (SE)	MMSE b (SE)
Psychological mistreatment	.080 (.040)*	.137 (.057)*	.113 (.138)	.789 (.700)	.055 (.248)
Physical mistreatment	−.167 (.117)	−.201 (.165)	.071 (.404)	−1.597 (2.079)	−1.449 (.713)*
Financial exploitation	.013 (.040)	.036 (.056)	−.008 (.136)	.993 (.705)	−.251 (.242)
Sexual mistreatment	−.125 (.255)	−.015 (.359)	−.747 (.882)	−6.048 (4.526)	.753 (1.558)
Caregiver neglect	−.226 (.036)***	−.390 (.051)***	−.435 (.126)***	−2.715 (.622)***	.141 (.227)

Baseline age, gender, education, income, medical comorbidities, ADL, depressive symptoms, social support, social strain, living arrangement, network size, and family composition have been controlled in regression models. *p < .05, *** p < .001.

With respect to different forms of EM and cognitive change, older adults with incident psychological mistreatment had a faster decrease in MMSE than those without psychological mistreatment at both waves (b = −.645, SE = .303, p < .05) (Table 2). Table 3 shows older adults with incident physical mistreatment had a faster decline in global cognition (b = −.401, SE = .140, p < .01), working memory (b = −1.207, SE = .480, p < .05), and MMSE (b = −2.369, SE = .950, p < .05) than those without physical mistreatment at both waves. Older adults with T1 physical mistreatment T2 no physical mistreatment had a faster decline in working memory than those without physical mistreatment at both waves (b = −1.034, SE = .371, p < .01). Table 4 presents older adults with incident caregiver neglect had a faster decline in global cognition (b = −.072, SE = .033, p < .05), episodic memory (b = −.110, SE = .050, p < .05), and processing speed (b = −2.273, SE = .714, p < .001) than those without caregiver neglect at both waves. Older adults with caregiver neglect at both waves had a greater decline in processing speed than the reference group (b = −3.176, SE = 1.530, p < .05). The relationship between financial exploitation and cognitive change (Table 5) as well as the relationship between sexual mistreatment and cognitive change (Appendix A) were not significant.

Table 2.

Association Between Psychological Mistreatment and Cognitive Change.

	Global cognition b (SE)	Episodic memory b (SE)	Working memory b (SE)	Processing speed b (SE)	MMSE b (SE)
Age	−.019 (.002)***	−.024 (.002)***	−.019 (.005)***	−.371 (.035)***	−.119 (.010)***
Female	−.027 (.021)	.012 (.032)	−.049 (.073)	−.866 (.481)	−.249 (.133)
Education	.023 (.003)***	.024 (.004)***	.110 (.009)***	.449 (.059)***	.153 (.016)***
Income	.020 (.009)*	.007 (.014)	.119 (.032)***	.731 (.213)***	.014 (.058)*
Medical comorbidities	.011 (.007)	.020 (.011)	.035 (.025)	.053 (.167)	.049 (.046)
ADL	−.032 (.007)***	−.051 (.009)***	−.067 (.021)**	−.355 (.154)*	−.177 (.045)***
Depressive symptoms	.003 (.003)	.001 (.004)	.001 (.009)	−.033 (.062)	.017 (.018)
Social support	.005 (.004)	.012 (.005)*	.013 (.012)	.107 (.081)	.014 (.022)
Social strain	−.008 (.009)	−.007 (.013)	.046 (.030)	−.373 (.202)	−.031 (.055)
Living arrangement	.004 (.006)	−.010 (.009)	.003 (.019)	.145 (.125)	.083 (.036)*
Network size	−.011 (.007)	−.009 (.010)	.029 (024)	.016 (.162)	−.133 (.044)**
Family composition	−.007 (.003)**	−.008 (.004)	−.011 (.009)	−.162 (.060)**	−.051 (.017)**
Baseline cognition	−.388 (.018)***	−.614 (.019)***	−.508 (.017)***	−.469 (.026)***	−.366 (.019)***
T1 no psychological mistreatment	1	1	1	1	1
T2 no psychological mistreatment (reference)
T1 psychological mistreatment	−.088 (.072)	−.127 (.110)	.165 (.245)	−2.007 (1.611)	−.173 (.457)
T2 psychological mistreatment
T1 psychological mistreatment	−.038 (.039)	−.074 (.060)	037 (.135)	1.127 (.902)	−.061 (.249)
T2 no psychological mistreatment
T1 no psychological mistreatment	−.010 (.048)	.127 (.073)	−.037 (.165)	−1.572 (1.085)	−.645 (.303)*
T2 psychological mistreatment

In each model, the baseline cognition is using the same measures with the cognitive outcome. Cognitive change = T2 cognition–T1 cognition. *p < .05, ** p < .01, *** p < .001.

Table 3.

Association Between Physical Mistreatment and Cognitive Change.

	Global cognition b (SE)	Episodic memory b (SE)	Working memory b (SE)	Processing speed b (SE)	MMSE b (SE)
Age	−.019 (.002)***	−.024 (.002)***	−.019 (.005)***	−.371 (.035)***	−.118 (.010)***
Female	−.028 (.021)	.010 (.032)	−.036 (.072)	−.828 (.479)	−.252 (.133)
Education	.023 (.003)***	.024 (.004)***	.111 (.009)***	.449 (.059)***	.152 (.016)***
Income	.020 (.009)*	.008 (.014)	.116 (.032)***	.738 (.213)***	.013 (.058)
Medical comorbidities	.011 (.007)	.019 (.011)	.035 (.025)	.063 (.167)	.054 (.046)
ADL	−.032 (.007)***	−.051 (.009)***	−.070 (.021)***	−.368 (.154)*	−.178 (.045)***
Depressive symptoms	.003 (.003)	−.000 (.004)	.003 (.009)	−.018 (.061)	.018 (.018)
Social support	.006 (.004)	.012 (.005)*	.010 (.012)	.110 (.081)	.018 (.022)
Social strain	−.012 (.008)	−.012 (.013)	.051 (.029)	−.392 (.196)*	−.044 (.053)
Living arrangement	.003 (.006)	−.009 (.009)	.001 (.019)	.122 (.125)	.081 (.036)*
Network size	−.011 (.007)	−.009 (.010)	.026 (.023)	.015 (.161)	−.128 (.044)**
Family composition	−.007 (.003)**	−.008 (.004)	−.012 (.009)	−.162 (.060)**	−.051 (.017)**
Baseline cognition	−.388 (.018)***	−.615 (.019)***	−.507 (.017)***	−.466 (.026)***	−.366 (.019)***
T1 no physical mistreatment	1	1	1	1	1
T2 no physical mistreatment (reference)
T1 physical mistreatment	.362 (.356)	.501 (.544)	1.258 (1.224)	8.337 (1.417)	−.860 (2.229)
T2 physical mistreatment
T1 physical mistreatment	−.201 (.108)	−.098 (.165)	−1.034 (.371)**	−4.257 (2.527)	−.233 (.676)
T2 no physical mistreatment
T1 no physical mistreatment	−.401 (.140)**	−.270 (.213)	−1.207 (.480)*	−5.034 (3.000)	−2.369 (.950)*
T2 physical mistreatment

In each model, the baseline cognition is using the same measures with the cognitive outcome. Cognitive change = T2 cognition–T1 cognition. *p < .05, ** p < .01, *** p < .001.

Table 4.

Association Between Caregiver Neglect and Cognitive Change.

	Global cognition b (SE)	Episodic memory b (SE)	Working memory b (SE)	Processing speed b (SE)	MMSE b (SE)
Age	−.019 (.002)***	−.023 (.002)***	−.019 (.005)***	−.351 (.036)***	−.117 (.010)***
Female	−.027 (.021)	.010 (.032)	−.043 (.072)	−.785 (.478)	−.250 (.133)
Education	.023 (.003)***	.024 (.004)***	.111 (.009)***	.456 (.059)***	.151 (.016)***
Income	.019 (.009)*	.006 (.014)	.116 (.032)***	.696 (.213)***	.012 (.058)
Medical comorbidities	.011 (.007)	.020 (.011)	.038 (.025)	.082 (.167)	.052 (.046)
ADL	−.030 (.007)***	−.048 (.010)***	−.065 (.022)**	−.294 (.158)*	−.183 (.046)***
Depressive symptoms	.003 (.003)	.000 (.004)	.002 (.009)	−.003 (.062)	.013 (.018)
Social support	.007 (.004)*	.014 (.005)**	.011 (.012)	.126 (.081)	.020 (.022)
Social strain	−.015 (.008)	−.015 (.013)	.048 (.029)	−.423 (.194)*	−.055 (.053)
Living arrangement	.006 (.006)	−.005 (.009)	.006 (.020)	.225 (.127)	.087 (.037)*
Network size	−.009 (.007)	−.008 (.010)	.026 (.024)	.052 (.162)	−.126 (.044)**
Family composition	−.008 (.003)**	−.008 (.004)*	−.012 (.009)	−.175 (.061)**	−.051 (.017)**
Baseline cognition	−.388 (.018)***	−.615 (.019)***	−.508 (.017)***	−.474 (.026)***	−.363 (.019)***
T1 no caregiver neglect	1	1	1	1	1
T2 no caregiver neglect (reference)
T1 caregiver neglect	−.068 (.071)	−.172 (.107)	−.293 (.240)	−3.176 (1.530)*	−.035 (.462)
T2 caregiver neglect
T1 caregiver neglect	.070 (.036)	.032 (.055)	.028 (.123)	.443 (.806)	.091 (.231)
T2 no caregiver neglect
T1 no caregiver neglect	−.072 (.033)*	−.110 (.050)*	−.070 (.114)	−2.273 (.714)***	−.131 (.210)
T2 caregiver neglect

In each model, the baseline cognition is using the same measures with the cognitive outcome. Cognitive change = T2 cognition–T1 cognition. *p < .05, ** p < .01, *** p < .001.

Table 5.

Association Between Financial Exploitation and Cognitive Change.

	Global cognition b (SE)	Episodic memory b (SE)	Working memory b (SE)	Processing speed b (SE)	MMSE b (SE)
Age	−.019 (.002)***	−.024 (.002)***	−.019 (.005)***	−.368 (.036)***	−.117 (.010)***
Female	−.027 (.021)	.012 (.032)	−.043 (.073)	−.832 (.480)	−.241 (.133)
Education	.023 (.003)***	.024 (.004)***	.111 (.009)***	.455 (.059)***	.151 (.016)***
Income	.021 (.009)*	.008 (.014)	.117 (.032)***	.758 (.213)***	.015 (.058)
Medical comorbidities	.010 (.007)	.018 (.011)	.036 (.025)	.040 (.167)	.046 (.046)
ADL	−.032 (.007)***	−.051 (.009)***	−.068 (.021)***	−.363 (.154)*	−.176 (.045)***
Depressive symptoms	.003 (.003)	−.000 (.004)	.001 (.009)	−.021 (.062)	.015 (.018)
Social support	.006 (.004)	.012 (.005)*	.011 (.012)	.108 (.081)	.017 (.022)
Social strain	−.012 (.008)	−.011 (.013)	.050 (.029)	−.357 (.198)	−.048 (.054)
Living arrangement	.004 (.006)	−.009 (.009)	.003 (.019)	.139 (.127)	.083 (.036)*
Network size	−.010 (.007)	−.009 (.010)	.028 (.024)	.017 (.161)	−.130 (.044)**
Family composition	−.007 (.003)**	−.008 (.004)	−.012 (.009)	−.162 (.060)**	−.050 (.017)**
Baseline cognition	−.387 (.018)***	−.615 (.019)***	−.509 (.017)***	−.468 (.026)***	−.365 (.019)***
T1 no financial exploitation	1	1	1	1	1
T2 no financial exploitation (reference)
T1 financial exploitation	.038 (.099)	.031 (.150)	.257 (.340)	−2.914 (2.265)	.406 (.618)
T2 financial exploitation
T1 financial exploitation	−.028 (.037)	−.033 (.056)	−.104 (.127)	−.232 (.871)	.113 (.233)
T2 no financial exploitation
T1 no financial exploitation	−.012 (.061)	.008 (.093)	.121 (.211)	.617 (1.461)	−.508 (.389)
T2 financial exploitation

In each model, the baseline cognition is using the same measures with the cognitive outcome. Cognitive change = T2 cognition–T1 cognition. *p < .05, ** p < .01, *** p < .001.

Discussion

This study provided some new insights into research on mistreatment and cognition by exploring the impact of EM on cognitive function in later life. The longitudinal study design allowed us to examine the relationship between EM and cognitive change over a 2-year period. Different forms of EM had different impacts on cognitive function. The impacts on cognition also varied among single victimization and revictimization. Our first hypothesis was partially supported by the finding that older adults with physical mistreatment were associated with lower MMSE at baseline. Older adults with caregiver neglect had lower global cognition, episodic memory, working memory, and processing speed at baseline. Our second hypothesis was also partially supported. Older adults with psychological mistreatment, physical mistreatment, and caregiver neglect had a faster decline in global cognition and cognitive domains.

EM and Cognitive Function at Baseline

Previous research reported that older adults with financial exploitation had poorer cognitive function than those without financial exploitation (DeLiema, 2017; Wood et al., 2014). This study goes beyond previous studies to explore cognitive function in older adults with psychological, physical, and sexual mistreatment; financial exploitation; and caregiver neglect. We found that physical function was associated with poorer MMSE. Caregiver neglect was associated with worse global cognition, episodic memory, working memory, and processing speed. However, psychological mistreatment was significantly associated with better global cognition and episodic memory. Our results suggesting that the effect of EM on cognitive function among older adults depends on the form of EM.

In contrast with the first hypothesis, the finding showed that psychological mistreatment was significantly associated with better global cognition and episodic memory. There are two possible explanations. First, developmental life span perspectives underlined the increasing ability of adaptation to stressors through life. These kind of reverse age effects have been attributed in part to older adults’ greater life experiences and greater prior experience in particular with adverse events (Knight et al., 2000). Older people appear to be better at regulating their emotional experience, show biases in attention and memory for positive information, and show greater skills at managing difficult interpersonal situations (Birditt & Fingerman, 2003). The absent negative impact of psychological mistreatment on cognitive function in our study may be explained by the improved emotional regulation skills in old age. A second possibility is EM was self-reported by participants in our study. Given the cross-sectional nature of these data, the association reflects a great ability of those with better cognitive function to report psychological mistreatment in interview. To the best of our knowledge, this study is among the first to examine the relationship between psychological mistreatment and cognitive function in older adults. Our study provides some preliminary findings in this area. Future research could further examine this relationship in other ethnic groups as well as explore whether the severity of psychological mistreatment will moderate its impact on cognitive function in older adults.

Impact of Different Forms of EM on Cognitive Decline

Our study advances knowledge by examining cognitive decline with respect to the exposure to EM over time. Different forms and duration of EM exert different effects on the change of cognitive function over a 2-year period. In terms of revictimization (i.e., T1 EM and T2 EM), we found that older adults with caregiver neglect at both waves were associated with a faster decline in processing speed than the reference group. Older adults with repeated exposure to EM may suffer from chronic stress. Chronic stress has been identified as a risk factor associated with cognitive decline in stress research (Lupien, 1997; Peavy et al., 2009).

Our findings suggest that incident EM (i.e., TI no EM and T2 EM) might be a sign for cognitive decline. Older adults with incident psychological mistreatment, physical mistreatment, and caregiver neglect had a faster decline in global cognition and cognitive domains than the reference group. Incident EM may lead to an increase in stress. Previous research found that an increase in stress over a 1-year period was associated with cognitive decline during the following year (Dickinson et al., 2011). Meanwhile, cognitive decline has been considered as a risk factor for EM in the literature. Future study could examine the causal relationship between incident EM and cognitive decline.

Baseline EM (i.e., T1 EM and T2 no EM) was also identified as a risk factor for cognitive decline. Older adults with T1 physical mistreatment but not T2 physical mistreatment had a faster decline in working memory. Existing research reported that greater levels of baseline perceived stress predicted cognitive slowing in attention, working memory, and processing speed across a 2-year period (Munoz et al., 2015). Baseline physical mistreatment could influence working memory in the following 2 years, while other forms of EM at baseline were not significantly associated with cognitive change. Given the significant relationship between perceived stress and cognitive slowing in working memory identified in previous research, future research could use structural equation modeling to test whether physical mistreatment leads to higher levels of stress that accelerate decline in working memory.

Exposure to Mistreatment and Cognitive Domains across Life Span

Earlier studies suggested that the most affected cognitive domains for individuals aged 7–18 years with mistreatment were visual episodic memory, executive function, and intelligence, while for individuals aged above 18 years with mistreatment were verbal episodic memory, visuospatial/problem solving, and attention (Masson et al., 2016). Our study found episodic memory, working memory, and processing speed were affected by EM for individuals aged 60 years and above. Future study could compare the magnitude of the effect of mistreatment on cognitive function in childhood, adulthood, and later life.

These results should be interpreted with caution. First, it is important to note that cognitive function was evaluated at time of interview, not at time of mistreatment, and that the cognitive profiles established in this study reflected a variable period of time after EM. Second, EM was self-reported by participants. Empirical data suggest that even participants with mild to moderate dementia can report meaningfully in survey studies. It is our experience from prior studies that even cognitively impaired persons can possess capacity to answer these very specific questions accurately and appropriately. Third, our results may underestimate the true association between EM and cognitive function as older adults with severe dementia was unable to take part in research studies. Fourth, the nonsignificant relationship between sexual mistreatment and cognitive function may be due to the small sample size of participants with sexual mistreatment. Future research could further explore the impact of sexual mistreatment on cognitive function of older adults in a large sample. Fifth, this study examined a sample of Chinese older immigrants living in the greater Chicago area. The findings may not be generalizable to Chinese older adults in other geographic areas. Sixth, there is no consensus regarding the definitions for EM. The relationship between EM and cognitive function could vary by the definition and severity of EM. It is necessary to pay attention to the definition of EM when interpreting the findings and comparing the findings with other studies.

Despite these limitations, this study was among the first using large-scale longitudinal data to explore the impact of EM on cognitive function in later life. This large population study was able to control for confounding variables for cognitive impairment, such as age, education, and depressive symptoms. The effect of EM on cognitive function appears to depend on the subtype of EM and the length of exposure to EM. Through evaluating different forms of EM and a broad range of cognitive domains, the findings suggested psychological and physical mistreatment, and caregiver neglect would deteriorate cognitive function. In addition, we used self-reported EM in the present study, which is different from earlier studies using APS data, informing the detection of EM cases could influence findings on EM and cognitive function. Selection bias may exist in APS EM sample, as many EM victims are reluctant to seek help from APS. It is more challenging to use APS data to study EM in ethnic minority populations given their language and cultural barriers which prohibited them from having access to APS. A population-based sample will be helpful to understand the relationship between EM and cognitive function in ethnic minority populations.

This study has wide-ranging implications for the provision of services, education, and care for older adults with different forms of EM. Conducting cognitive tests with EM victims can provide important information about their mental and cognitive status and behaviors. As a result, health professionals, service providers, and caregivers can develop a greater understanding of how EM affects their cognitive decline. When serving EM victims, it is necessary to not only prevent them from repeated violence but also protect their cognitive health. Our findings inform interventions could target specific cognitive domains, given the varying relationships between EM and different cognitive domains. Interventions on preventing cognitive decline of EM victims may also pay attention to the subtype and duration of EM experienced by victims. Early targeted interventions, such as cognitive training, are suggested to be provided for older adults with incident EM to slow their cognitive decline. Stress management intervention might be considered to improve the stress management and emotional regulation skills of victims to cope with EM and reduce the negative impact of EM on cognitive function. Social services could be provided for older adults with caregiver neglect to support their daily activities and in turn protect their cognitive health.

Conclusion

In this study, we tested the relationships between different forms of EM and cognitive change. The findings provide valuable insights into the cognitive health of EM victims and suggest healthcare professionals and social service providers could pay attention to the change of cognitive function in certain domains and implement early interventions. Integrating our finding in late adulthood together with existing research in childhood and adulthood, the full spectrum of mistreatment and cognition across the life span is present.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Dr. Li’s pilot project was supported by National Institute on Aging (P30AG059304) and Alzheimer’s Association (AARG-NTF-20-684568). Dr. Dong was supported by National Institute on Aging (P30AG059304, R01AG042318), National Institute of Nursing Research (R01NR014846), National Institute of Minority Health and Health Disparities (R01MD006173), and National Institute of Mental Health (R34MH100443).

ORCID iD

Mengting Li

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