Elder abuse

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Elder abuse is a general term used to describe certain types of harm to older adults. Other terms commonly used include: "elder mistreatment," "senior abuse," "abuse in later life," "abuse of older adults," "abuse of older women," and "abuse of older men."

One of the more commonly accepted definitions of elder abuse is "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."^[1] This definition has been adopted by the World Health Organization from a definition put forward by Action on Elder Abuse in the UK.

The core feature of this definition is that it focuses on harms where there is "expectation of trust" of the older person toward their abuser. Thus, it includes harms by people the older person knows or with whom they have a relationship, such as a spouse, partner or family member, a friend or neighbor, or people that the older person relies on for services. Many forms of elder abuse are recognized as types of domestic violence or family violence.

The term elder abuse does not include general criminal activity against older persons, such as home break ins, "muggings" in the street or "distraction burglary", where a stranger distracts an older person at the doorstep while another person enters the property to steal.

The abuse of elders by caretakers is a worldwide issue. In 2002, the work of the World Health Organization brought international attention to the issue of elder abuse.^[2] Over the years, government agencies and community professional groups, worldwide, have specified elder abuse as a social problem.^[3]

In 2006 the International Network for Prevention of Elder Abuse (INPEA) designated June 15 as World Elder Abuse Awareness Day (WEAAD) and an increasing number of events are held across the globe on this day to raise awareness of elder abuse, and highlight ways to challenge such abuse.^[4]

Types

Although there are common themes of elder abuse across nations, there are also unique manifestations based upon history, culture, economic strength, and societal perceptions of older people within nations themselves. The fundamental common denominator is the use of power and control by one individual to affect the well-being and status of another, older, individual.

There are several types of abuse of older people that are generally recognized as being elder abuse, including:

• Physical: e.g. hitting, punching, slapping, burning, pushing, kicking, restraining, false imprisonment/confinement, or giving excessive or improper medication
• Psychological/Emotional: e.g. shouting, swearing, frightening, or humiliating a person. A common theme is a perpetrator who identifies something that matters to an older person and then uses it to coerce an older person into a particular action. It may take verbal forms such as name-calling, ridiculing, constantly criticizing, accusations, blaming, and general disrespect, or non verbal forms such as ignoring, silence or shunning.
• Financial abuse: also known as financial exploitation. e.g. illegal or unauthorized use of a person’s property, money, pension book or other valuables (including changing the person's will to name the abuser as heir). It may be obtained by deception, coercion, misrepresentation, undue influence, or theft. The term includes fraudulently obtaining or use of a power of attorney. Other forms include deprivation of money or other property, or by eviction from own home
• Scam by strangers: e.g. worthless "sweepstakes" that elderly persons must pay in order to collect winnings, fraudulent investment schemes, predatory lending, and lottery scams.^[5]
• Sexual: e.g. forcing a person to take part in any sexual activity without his or her consent, including forcing them to participate in conversations of a sexual nature against their will; may also include situations where person is no longer able to give consent (dementia)
• Neglect: e.g. depriving a person of food, heat, clothing or comfort or essential medication and depriving a person of needed services to force certain kinds of actions, financial and otherwise. The deprivation may be intentional (active neglect) or happen out of lack of knowledge or resources (passive neglect).

In addition, some U.S. state laws ^[6] also recognize the following as elder abuse:

• Rights abuse: denying the civil and constitutional rights of a person who is old, but not declared by court to be mentally incapacitated. This is an aspect of elder abuse that is increasingly being recognized and adopted by nations
• Self-neglect: elderly persons neglecting themselves by not caring about their own health or safety. Self neglect (harm by self) is treated as conceptually different than abuse (harm by others).
• 'Abandonment': deserting a dependent person with the intent to abandon them or leave them unattended at a place for such a time period as may be likely to endanger their health or welfare.^[7]

Institutional abuse refers to physical or psychological harms, as well as rights violations in settings where care and assistance is provided to dependant older adults or others.

Signs

The signs of abuse vary considerably among older people and with the type of harm being experienced. An older person who is being abused may:

• Say she or he is being harmed
• Seem depressed and withdrawn; signs of depression in elders are not getting dressed, not performing basic care of themselves that they are able to do, never going out even if they can, inability to sleep or sleeping too much
• Not accepting invitations to spend time away from their family or a caregiver
• Seem afraid to make their own decisions
• Seem to be hiding something about a caregiver
• Not have any spending money
• Put off going to the doctor
• Feel anxious and fearful
• Try to "run away," leaving their place of residence and not wishing to return
• Seem to have too many household "accidents"^[8]

Any of these potential signs can indicate problems other than abuse or neglect, and none of these "prove" there is harms occurring. The presence of the signs simply indicate that further inquiry may be necessary.

Health consequences of elder abuse

The health consequences of elder abuse are very serious. Elder abuse can destroy an elderly person's quality of life in the forms of: ^[9]

• Declining functional abilities
• Increased dependency
• Increased sense of helplessness
• Increased stress
• Worsening psychological decline
• Premature mortality and morbidity
• Depression and dementia
• Malnutrition
• Death

The risk of death for elder abuse victims are three times higher than for non-vicitms.^[10]

Common abusers of older people

An abuser can be a spouse, partner, relative, a friend or neighbor, a volunteer worker, a paid worker, practitioner, solicitor, or any other individual with the intent to deprive a vulnerable person of their resources. Relatives include adult children and their spouses or partners, their offspring and other extended family members. Children and living relatives who have a history of substance abuse or have had other life troubles are of particular concern.

Perpetrators of elder abuse can include anyone in a position of trust, control or authority. Family relationships, neighbors and friends, are all socially considered as relationships of trust, whether or not the older adult actually thinks of the people as "trustworthy". Some perpetrators may "groom" an older person (befriend or build a relationship with them) in order to establish a relationship of trust. Older people living alone who have no adult children living nearby are particularly vulnerable to "grooming" by neighbors and friends who would hope to gain control of their estates.

The majority of abusers are relatives, typically the older adult's spouse/partner or sons and daughters, although the type of abuse differs according to the relationship. In some situations the abuse is "domestic violence grown old," a situation in which the abusive behaviour of a spouse or partner continues into old age.

In some situations, an older couple may be attempting to care and support each other and failing, in the absence of external support. With sons and daughters it tends to be financial abuse, justified by a belief that it is nothing more than the "advance inheritance" of property, valuables and money.

Within paid care environments, abuse can occur for a variety of reasons. Some abuse is the willful act of cruelty inflicted by a single individual upon an older person. In fact, a case study in Canada suggests that the high elder abuse statistics are from repeat offenders who, like in other forms of abuse, practice elder abuse for the Schadenfreude associated with the act. Nick Klassen, a practitioner of elder abuse involved in the above mentioned Canadian case study, described how some perpetrators of elder abuse tend to feel somewhat of an ecstasy, high, or sense of satisfaction while performing acts of abuse on the elderly. More commonly, institutional abuses or neglect may reflect lack of knowledge, lack of training, lack of support, or insufficient resourcing. Institutional abuse may be the consequence of common practices or processes that are part of the running of a care institution or service. Sometimes this type of abuse is referred to as "poor practice," although it is important to recognize that this term reflects the motive of the perpetrator (the causation) rather than the impact upon the older person.

With the aging of today's population, there is the potential that elder abuse will increase unless it is more comprehensively recognized and addressed.

Risk factors for elder abuse

There are several risk factors, which increase the likelihood that an elderly person will become a victim of elder abuse. Such risk factors for elder abuse include an elderly person who: ^[11]

• Has memory problems (such as dementia)
• Has physical disabilities
• Has depression, loneliness, or lack of social support
• Abuses alcohol or other substances
• Is verbally or physically combative with the caregiver
• Has a shared living situation

There are also several risk factors, which increase the likelihood that a caregiver will participate in elder abuse. Such risk factors for elder abuse include a caregiver who: ^[11]

• Feels overwhelmed or resentful
• Has a history of substance abuse or a history of abusing others
• Is dependent on the older person for housing, finances, or other needs
• Has mental health problems
• Is unemployed
• Has a criminal history
• Has a shared living situation

Barriers to obtaining elder abuse statistics

Several conditions make it hard for researchers to obtain accurate statistics on elder abuse. Researchers may have a hard time obtaining accurate elder abuse statistics for the following reasons:

• Elder abuse is largely a hidden problem and tends to be committed in the privacy of the elderly person's home, mostly by his or her family members^[12]
• Elder abuse victims are often unwilling to report their abuse for fear of others' disbelief, fear of loss of independence, fear of being institutionalized, fear of losing their only social support (especially if the perpetrator is a relative), and fear of being subject to future retaliation by the perpetrator(s)^[13], ^[14], ^[15]
• Elder abuse victims' cognitive decline and ill health may prevent them from reporting their abuse^[16]
• Lack of proper training of service providers, such as social workers, law enforcement, nurses, etc., about elder abuse, therefore the number of cases reported tend to be low^[17]

Elder abuse statistics

There has been a general lack of reliable data in this area and it is often argued that the absence of data is a reflection of the low priority given to work associated with older people. However, over the past decade there has been a growing amount of research into the nature and extent of elder abuse. The research still varies considerably in the definitions being used, who is being asked, and what is being asked. As a result, the statistics used in this area vary considerably.

One study suggests that around 25% of vulnerable older adults will report abuse in the previous month, totaling up to 6% of the general elderly population.^[18] However, some consistent themes are beginning to emerge from interaction with abused elders, and through limited and small scale research projects. Work undertaken in Canada suggests that approximately 70% of elder abuse is perpetrated against women and this is supported by evidence from the AEA helpline in the UK, which identifies women as victims in 67% of calls. Also domestic violence in later life may be a continuation of long term partner abuse and in some cases, abuse may begin with retirement or the onset of a health condition.^[19] Certainly, abuse increases with age, with 78% of victims being over 70 years of age.^[20]

The higher proportion of spousal homicides supports the suggestion that abuse of older women is often a continuation of long term spousal abuse against women. In contrast, the risk of homicide for older men was far greater outside the family than within.^[21] This is an important point because the domestic violence of older people is often not recognized and consequently strategies, which have proved effective within the domestic violence arena, have not been routinely transferred into circumstances involving the family abuse of older people.

According to the AEA helpline in the UK, abuse occurs primarily in the family home (64%), followed by residential care (23%), and then hospitals (5%), although a helpline does not necessarily provide a true reflection of such situations as it is based upon the physical and mental ability of people to utilize such a resource.^[20]

Abandonment

Elder abuse can also include deserting an elderly, dependent person with the intent to abandon them or leave them unattended at a place for such a time period as may be likely to endanger their health or welfare.^[7]

Self-abuse and neglect

Older adults may neglect themselves by not taking care of or caring about their own personal health and well-being.^[22] Elder self-neglect can lead to illness, injury, or even death. Common needs that older adults may deny themselves, or ignore are the following:

• Sustenance (food or water)
• Cleanliness (bathing and personal hygiene)
• Adequate clothing for climate protection
• Proper shelter
• Adequate safety
• Clean and healthy surroundings
• Medical attention for serious illness
• Essential medications

Self neglect is often created by an individual's declining mental awareness or capability.

Some older adults may choose to deny themselves some health or safety benefits, which may not be self-neglect. This may simply be their personal choice. Caregivers and other responsible individuals must honor these choices if the older adult is sound of mind. In other instances, the older adult may lack the needed resources, as a result of poverty, or other social condition. This is also not considered as "self neglect".

Research

Research conducted in New Zealand broadly supports the above findings, with some variations. Of 1288 cases in 2002–2004, 1201 individuals, 42 couples, and 45 groups were found to have been abused. Of these, 70 percent were female. Psychological abuse (59%), followed by material/financial (42%), and physical abuse (12%) were the most frequently identified types of abuse. Sexual abuse occurred in 2 percent of reported cases.^[23]

Age Concern New Zealand found that most abusers are family members (70%), most commonly sons or daughters (40%). Older abusers (those over 65 years) are more likely to be husbands.^[23]

In 2007, 4,766 cases of suspected abuse, neglect, or financial exploitation involving older adults were reported, an increase of 9 percent over 2006. Tragically, 19 incidents were related to a death, and a total of 303 incidents were considered life-threatening. About one in 11 incidents involved a life-threatening or fatal situation.

Prevention of elder abuse

Doctors, nurses, and other medical personnel can play a vital role in assisting elder abuse victims. Studies have show that elderly individuals, on average, make 13.9 visits per year to a physician.^[24] Although there has been an increase in awareness of elder abuse over the years, physicians tend to only report 2% of elder abuse cases.^[9] Reasons for lack of reporting by physicians include a lack of current knowledge concerning state laws on elder abuse, concern about angering the abuser and ruining the relationship with the elderly patient, possible court appearances, lack of cooperation from elderly patients or families, and lack of time and reimbursement.^[9] Through education and training on elder abuse, health care professionals can better assist elder abuse victims.

Educating and training those in the criminal justice system, such as police, prosecutors, and the judiciary, on elder abuse, as well as increased legislation to protect elders, will also help to minimize elder abuse and will also provide improved assistance to victims of elder abuse.

In addition, community involvement in responding to elder abuse can contribute to elderly persons' safety. Communities can develop programs that are structured around meeting the needs of elderly persons. For example, several communities throughout the United States have created Financial Abuse Specialist Teams[2], which are multi-disciplinary groups that consist of public and private professionals who volunteer their time to advise Adult Protective Services (APS), law enforcement, and private attorneys on matters of vulnerable adult financial abuse.^[25]

Where to get help

For those over the age of 60, help is available through local Area Agencies on Aging (AAA) that include older adult protective services as an important component of their aging services. The phone number for local AAA offices can be found in the phone book blue pages under Abuse/Assault.^[8]

National Center on Elder Abuse The National Center on Elder Abuse (NCEA) serves as a national resource center dedicated to the prevention of elder mistreatment. First established by the U.S. Administration on Aging (AoA) in 1988 as a national elder abuse resource center, the NCEA was granted a permanent home at AoA in the 1992 amendments made to Title II of the Older Americans Act.

National Committee for the Prevention of Elder Abuse (NCPEA) The National Committee for the Prevention of Elder Abuse is an association of researchers, practitioners, educators, and advocates dedicated to protecting the safety, security, and dignity of America’s most vulnerable citizens. It was established in 1988 to achieve a clearer understanding of abuse and provide direction and leadership to prevent it.

The Center for Elders and the Courts (CEC) The Center for Elders and the Courts serves as a national resource center dedicated to serving courts throughout the United States on issues related to aging, probate, and elder abuse. The Center for Elders and the Courts provides information on current legislation on elder abuse in each state throughout the United States.

See also

• Adult Protective Services
• Aging in place
• Assisted living
• Elderly care
• Institutional abuse
• Psychological abuse
• Psychological manipulation
• The Weinberg Center for Elder Abuse Prevention

References

1. ^ [1], Action on Elder Abuse, accessed October 12, 2007.
2. ^ Cook-Daniels,L., (2003b, January/February). "2003 is the year elder abuse hits the international state." Victimization of the Elderly and Disabled. 5, 65-66, 76.
3. ^ Rinkler, A.G., (2009). "Recognition and perception of elder abuse by prehospital and hospital-based care providers." Archives of Gerontology and Geriatrics. 48, 110-115.
4. ^ International Network for the Prevention of Elder Abuse, accessed June 26, 2007.
5. ^ Shilling, D. (2008, November/December). "Improving the court system's response to elder abuse," Victimization of the Elderly and Disabled, 11, 49, 51-52, 59, 62-63.
6. ^ Nursing Home Abuse Laws (NHAL), http://www.nursinghomeabuselaws.org/elders/
7. ^ ^{a b} Oregon Revised Statutes.
8. ^ ^{a b} Institute for Good Medicine at the Pennsylvania Medical Society, http://www.myfamilywellness.org/MainMenuCategories/FamilyHealthCenter/DomesticViolence/ElderAbuse.aspx
9. ^ ^{a b c} Dong, X. (2005). "Medical Implications of Elder Abuse and Neglect." Clinics in Geriatric Medicine. 21:293-313.
10. ^ American Medical Association White Paper on Elderly Health. (1990). "report on the Council on Scientific Affairs." Arch Intern Med. 150:2459-72.
11. ^ ^{a b} Hildreth, C.J., (August 2011). "Elder Abuse." JAMA. 306(5): 568. doi:0.1001/jama.306.5.568
12. ^ Administration on Aging. (1998). The national elder abuse incidence study: Final report. [Online], Available:www.aoa.gov/abuse/report/default.html
13. ^ Acierno, R., Hernandex-Tejada, M., Muzzy, W., and Steve, K. (2009). The national elder mistreatment study (NCJ Publication No. 2264560. Washington, DC: U.S. Department of Justice
14. ^ Bulman, P., (April 2010). "Elder abuse emerges form the shadows of public consciousness."NIJ Journal. 265, 4-7.
15. ^ Klein, A., Tobin, T., Salomon, A., and Dubois, J. (2008). A statewide profile of abuse of older women and the criminal justice response (NCJ Publication No. 222459). Washington, DC: U.S. Department of Justice.
16. ^ Choi, N.G., and Mayer, J. (2000). "Elder Abuse, Neglect, and Exploitation." Journal of Gerontological Social Work, 33(4), 5-25. doi:http://dx.doi.org/10.1300/J083v33n02_02
17. ^ Laumann, E.O., Leitsch, S.A., and Waite, L.J. (2008). "Elder mistreatment in the United States: Prevalence estimate from a nationally representative study." Journals of Gerontology: Series B, Psychological Sciences and Social Sciences, 63 (4), S248-S254
18. ^ Cooper C, Selwood A, Livingston G (March 2008). "The prevalence of elder abuse and neglect: a systematic review". Age Ageing 37 (2): 151–60. doi:10.1093/ageing/afm194. PMID 18349012. http://ageing.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=18349012. 
19. ^ Silent and Invisible: A Report on Abuse and Violence in the Lives of Older Women in British Columbia and Yukon, 2001.
20. ^ ^{a b} Hidden Voices, Action on Elder Abuse, 2005.
21. ^ Statistics Canada, 1999, 38.
22. ^ Tina de Benedictis, Ph.D., Jaelline Jaffe, Ph.D., and Jeanne Segal, Ph.D., (2007) Elder Abuse Types, Signs, Symptoms, Causes, and Help. Helpguide, helpguide.org.
23. ^ ^{a b} Age Concern Elder Abuse and Neglect Prevention Services: An Analysis of Referrals for the period 1 July 2002 to 30 June 2004. Age Concern New Zealand, November 2005.
24. ^ Federal Interagency Forum on Aging-Related Statistics. Older Americans 2008: Key indicators of well-being. Federal Interagency Forum on Aging-Related Statistics, Washington, DC: Government Printing Office, March 2008.
25. ^ Council on Aging Orange County, http://www.coaoc.org/html/services_fast_description.htm

Further reading

• Nerenberg, Lisa Elder Abuse Prevention: Emerging Trends and Promising Strategies (2007)

External links

• Administration on Aging website
• Action on Elder Abuse website
• Canadian Network for the Prevention of Elder Abuse
• Center of Excellence on Elder Abuse & Neglect
• Elder Abuse Prevention Video Training
• International Network for the Prevention of Elder Abuse website (INPEA)
• National Adult Protective Services Association
• National Association for Home Care & Hospice
• National Center For Elder Abuse (NCEA)
• National Clearing House on Abuse in Later Life
• The Centers for Elders and the Courts (CEC)
• The National Committee for the Prevention of Elder Abuse (NCPEA)
• World Health Organization website
• Website of European project for the Prevention of Elder Abuse, funded by the European Commission