- Open Access
- Published: 28 March 2022
Experiences of elder abuse: a qualitative study among victims in Sweden
- Mikael Ludvigsson 1 , 2 ,
- Nicolina Wiklund 1 ,
- Katarina Swahnberg 3 &
- Johanna Simmons 1
BMC Geriatrics volume 22 , Article number: 256 ( 2022 ) Cite this article
Elder abuse is underreported and undertreated. Methods for prevention and intervention are being developed, but the knowledge guiding such measures is often insufficiently based on the victims’ own voices due to a paucity of studies. The aim of this study was therefore to explore experiences of elder abuse among the victims themselves.
Consecutive inpatients ≥ 65 years of age at a hospital clinic in Sweden were invited to participate, and 24 victims of elder abuse were identified. Semi-structured qualitative interviews were conducted, and transcripts were analyzed using qualitative content analysis.
The analysis generated four themes that together give a comprehensive picture of elder abuse from the participants’ subjective perspectives. The participants’ experiences of abuse were similar to previous third-party descriptions of elder abuse and to descriptions of abuse among younger adults, but certain aspects were substantially different. Vulnerability due to aging and diseases led to dependance on others and reduced autonomy. Rich descriptions were conveyed of neglect, psychological abuse, and other types of abuse in the contexts of both care services and family relations.
Elder abuse is often associated with an individual vulnerability mix of the aging body, illnesses, and help dependence in connection with dysfunctional surroundings. As individual differences of vulnerability, exposure to violence, and associated consequences were so clear, this implies that components of prevention and intervention should be individually tailored to match the needs and preferences of older victims.
Peer Review reports
Abuse of older adults is recognized as a pervasive and serious problem in society. Prevalence estimates have ranged from 10% upwards in cognitively intact persons from North and South America, with large variations between different countries and subcategories of the population [ 1 , 2 , 3 ]. Elder abuse is defined by the World Health Organization (WHO) as “a single or repeated act or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person”. It includes five different types of abuse: physical abuse, psychological abuse, sexual abuse, economic abuse, and neglect [ 4 ]. Elder abuse is associated with various adverse health outcomes including psychosocial distress, morbidity, and mortality [ 1 ]. Exposure to more than one type of abuse or by more than one perpetrator is called poly-victimization, and this common condition is generally associated with even worse health outcomes than single exposure to abuse [ 5 , 6 ]. It is also increasingly acknowledged that elder abuse is associated with previous experiences of violence in childhood and adulthood, motivating a life-course perspective in research on elder abuse [ 7 , 8 ].
The causes and mechanisms of elder abuse are important to understand, to prevent its occurrence more effectively in society. The socio-ecological model (Fig. 1 ) of abuse describes how abuse can be understood as a complex interplay between risk factors on different social levels (individual, relationship, community, or societal level) for the victim [ 5 , 9 ]. By analyzing and handling abuse with help of this model, the circumstances of abuse are concretized which facilitates practical interventions. However, experiences of elder abuse differ between professionals, other surrounding persons, and the older adults themselves [ 10 , 11 ], and the varying conceptions and definitions used have consequences for the types and forms of interventions planned. If supportive resources are not adapted to the victims’ conceptualizations of elder abuse or to their perceived needs, the resources risk being ineffective [ 1 , 12 , 13 ]. Thus, the voices of the victims themselves are important to truly understand their associated needs as well as the causes and mechanisms of elder abuse, in order to develop more effective interventions.
The socioecological model inspired by Bronfenbrenner [ 9 ] and Heise [ 14 ] as a mean to understand the complexity of elder abuse
Furthermore, qualitative studies have been proposed to better understand conceptual and cultural variations of elder abuse [ 1 ]. Some qualitative studies on abuse of older adults have been undertaken within a theoretical framework of intimate partner violence (IPV; [ 15 , 16 ]), but this framework differs from the framework of elder abuse for example by underestimating the categories of abused men, neglect, and abuse by personnel in healthcare or long-term care [ 17 , 18 , 19 ]. Abuse in healthcare and long-term care are particularly relevant for a comprehensive picture of elder abuse as increasing proportions of the population encounter such institutions due to increasing age, frailty, and social dependence [ 2 , 20 ].
Within the framework of elder abuse, several qualitative studies have asked professionals or other third parties about elder abuse [ 11 , 21 , 22 ], but only few have asked the victims themselves [ 21 , 23 , 24 ]. However, these few previous studies do not offer a sufficiently comprehensive picture of the matter which is why we conducted the present study.
The aim of this study was to explore experiences of elder abuse among the victims themselves. By asking the victims directly, our understanding of elder abuse can hopefully deepen and this in turn is essential for adequate prevention and intervention.
Design, setting and sample
Semi structured qualitative interviews were conducted and analyzed using content analysis. The sample was 24 participants from the larger REAGERA (Responding to Elder Abuse in GERiAtric care) project, which included developing and validating the screening instrument REAGERA-S for detecting elder abuse in healthcare [ 25 ]. Consecutive older adults ≥ 65 years of age admitted to a hospital clinic for both acute geriatric and acute medical patients were eligible for inclusion. The consecutive sampling was chosen in the pursuit of naturalistic openness, and this sampling was expected to lead to a wider range of abuse (including mild forms of abuse), compared to alternative purposeful sampling strategies. A parallel goal of gathering information-rich data was reached through a relatively large number of participants. Exclusion criteria were insufficient somatic, cognitive, or linguistic capacity to answer the screening instrument either independently or with the help of healthcare personnel. Patients at the clinic were mostly admitted from the emergency department, and the mean duration of stay for patients over 65 years was 10 days at the acute geriatric ward and 4 days at the acute medical ward during the study period. The setting is described in greater detail elsewhere [ 25 ]. Between January and June 2018, 306 potential participants were asked to participate by nurses on the ward. The screening instrument was completed by 191 participants, of which 135 were interviewed. Of these 135 participants, 24 had been victims of elder abuse and all their 24 recorded interviews were included for this qualitative study. Descriptive data about the 24 included participants are presented in Table 1 . Typically for the setting of the hospital clinic, the mean age was rather high, as were the number of medications and the degree of social dependence for managing activities of daily living—compared to an average patient in health care.
Before the interview, a nurse on the ward distributed a questionnaire to potential participants including the screening instrument REAGERA-S [ 25 ], as well as information about voluntary participation and informed consent. The screening instrument included nine questions about different kinds of abuse (e.g." Has anyone attempted to control you, limit your contact with others, or decide what you may or may not do?”;”Have you been subjected to any form of physical violence, for example being shoved, pinched, held down, hit or kicked?”), and one question about associated suffering. The instrument in total is available elsewhere [ 25 ]. No precise definition of elder abuse was presented for the participants before the interviews. Rather the information preceding the interviews included rather vague descriptions of elder abuse (e.g. “to be subjected to negative actions”) to prevent steering the participants’ thoughts or stories for the data collection. Later that same day or the following day, a qualitative interview was conducted in a private room. The interview was semi-structured using a prepared interview guide (see Supplement 1 ), with four main topics to cover (experiences of abuse, associated thoughts and feelings, effects of the abuse, and support after the abuse). The informants’ experiences of abuse are presented in this study, while their experiences of coping with abuse and their desired support are presented in a separate paper.
For the interviews, we used open-ended questions such as “Can you tell me some more about what you were exposed to?” and “What are your feelings when you think about this today?”. Probing and supplementary questions were also asked. The interviews were audio recorded and transcribed verbatim. The length of the interviews varied between 12 and 97 min. Field notes were written during or after the interviews. Just after each formal interview, the previously completed questionnaire was quickly checked for severe depression or suicidal risk. In two cases, this check – together with the interview – resulted in a referral to an appropriate care unit for support connected to being abused. The individual’s responses from the REAGERA-S were used at a later stage when classifying cases of elder abuse after the interview, described in more detail elsewhere [ 25 ]. All participants received both oral and written information about support services to contact in case of need. In addition to checking the participants’ psychological wellbeing and perceptions of participation in the interviews, additional follow-ups were carried out by phone by the researchers about 1–2 weeks after the interviews. All participants gave written informed consent at the time of participation. A potential ethical problem of the consent process was the principal vulnerability of the participant in the hospital care setting. The interviewers (three of the researchers: JS, NW and ML) usually work as physicians but were not involved in the formal care of the participants, and this was communicated to the patients orally and through a civilian clothing. By signaling thus that the interviewers were separate from the formal health care personnel, elements of vulnerability and potential dependency of the participant was prevented in the participation. Also, security and rapport were built in the meeting through active listening and validation. The study was conducted in accordance with the principles of the Declaration of Helsinki and approved by the Regional Ethics Review Board in Linköping, Sweden (2017/181–31; 2017/564–32).
Transcripts were analyzed using qualitative content analysis, based on Graneheim and Lundman [ 26 ] and a hermeneutic standpoint with an intermediate level of abstraction and interpretation [ 27 ]. For the purpose of exploring individual experiences, the qualitative content analysis was considered an appropriate method with a focus on subject, context and variation of the data [ 27 ]. The process of analysis involved the following steps: 1) repeated preliminary readings of unique interviews to obtain a sense of the whole; 2) dividing the text into units of meaning; 3) giving codes to condensed meaning units; 4) abstraction within and between interviews by aggregating codes into tentative subcategories/categories (manifest content), and subthemes/themes (latent interpretive content); 5) discussion and revision of tentative codes, subthemes/themes, and subcategories into more definitive ones. The analysis included both a search for convergent patterns and a mirror analytical strategy to investigate divergence (consideration of data that did not fit the dominant patterns) [ 28 ].
Six interviews were coded separately and were then discussed together by all the authors. For the remaining interviews, the coding and development of tentative subcategories and themes were carried out by two of the authors (ML and JS; steps 1–4). The tentative themes/subthemes were then discussed and revised (step 5) by all the authors together. This validation within the research group aimed to strengthen the research design, not by identical statements or consensus but as a form of reflexivity through contesting and supplementing each other’s readings [ 29 ]. The QSR International’s NVivo 12 software program was used as a means for sorting and managing data during the process.
The qualitative analysis generated four themes which are presented in detail below: vulnerability in old age; experiences from earlier in life; perceptions of abuse; consequences and suffering from the abuse. An overview of the themes subthemes and subcategories is depicted in Fig. 2 .
Coding tree as an overview of the themes, subcategories, and subthemes of the qualitative content analysis
Vulnerability in old age
The participants described their life situations as contexts for the adverse events they had been subjected to, and these descriptions expressed a general pattern of vulnerability. This vulnerability largely consisted of different kinds of dependence on other people: social, physical, and medical dependence. Social dependence sometimes reflected efforts to avoid loneliness, conflicts, sorrow, or other adversities for the family members.
Physical dependence could be the need to get a ride to visit friends, or a need for assistance with putting on socks due to reduced mobility, while medical dependence could be a need for assistance with injection treatment. The participants’ vulnerability was due to the natural consequences of normal aging, including a lack of energy or reduced mobility, or the consequences of illness, with reduced capacity for activities and participation. It was also a result of social relationships that had evolved over the course of a long lifetime. When participants asked for help or received help from those around them, they consequently had reduced defense against or increased vulnerability to abuse.
“Well, I’m not a happy person any longer, I’m hardly allowed to laugh, because he doesn’t like that really. […] And I also don’t get outdoors like I did before. Then I could take the bus downtown and go shopping and do whatever I wanted. Now he’s behind my wheelchair, checking me all the time, and that’s not fun.” (Woman, ID 9, 71 years).
The participants often expressed a desire to overcome their dependence, either by managing on their own or by finding alternative helpers. Thus, the dependency was often related to a specific perpetrator, but also in general related to any potential helper. However, a lack of energy or failing capacities during old age often resulted in dependence remaining. As a part of their vulnerability, the participants also expressed that it was hard to defend themselves when exposed to abusive situations:
“… if you have employees who behave a little badly to you, that’s different [that’s one thing]… But if you encounter resistance in healthcare, that’s another story.” (Man, ID 19, 85 years).
How the participants related to their vulnerability or their dependence varied, although a common approach was the desire not to bother their helpers (relatives or personnel).
“[There were] times when they [the care personnel] didn’t come. They have… they had a shortage of staff, and when some of them got sick they skipped [visiting some patients], and I was probably the one they cared about the least, as I was the most alert of us.” (Man, ID 1, 85 years).
Reduced autonomy was also described as an aspect or a consequence of dependence on help, whereby the older adults were not allowed to decide, or could not decide, about their life situation. Their autonomy was sometimes reduced by the limited willingness or ability of those around them to meet their needs. On other occasions, their autonomy was reduced by their physical or social impairments. For example, they were sometimes not allowed to decide where to live, or which activities to engage in.
“And they’re talking about putting me there again [in the nursing home], and I don’t want that, but what the hell can I do [about it]?” (Man, ID 1, 85 years).
The participants also expressed their perceptions of limited autonomy when they were treated like objects rather than individuals, or when the personnel did not show any interest or engagement in their personal needs, desires, or personality. For instance, all residents at the nursing home were invited – or sometimes rather forced – to participate in certain specific activities, due to the mistaken ageist notion that all older adults enjoy the same sort of activities. Thus, the older adults perceived reduced autonomy when grudgingly participating in bingo competitions.
The participants also conveyed their theories about why their dependence became so problematic, and these theories were often about specific members of staff being perceived as unfriendly or incompetent. Other theories related to how structural deficiencies of society – or of healthcare, or of certain organizations – contributed to a general lack of humanity among the older adults’ potential helpers. An example of such a perceived structural deficiency is when financial savings made by an organization are allowed to trump care quality or staff competence in healthcare. Accordingly, a recurrently suggested intervention to prevent elder abuse would be to educate the care staff:
Interviewer: “How would it be possible to … [prevent age-discriminatory care by the assisted living]? Participant: “By educating the care staff, of course…. So to [that they would] understand that an older adult has a background whatever that may be./…/. Perhaps education [for them], to understand the individual, so to say”. (Woman, ID 3, 84 years).
Experiences from earlier in life
In addition to the above descriptions of vulnerability during old age, the participants also spoke about their earlier lives, including time of adversity and joy. Several older participants described that, during old age and beforehand, they could receive strength or support from a friend or a partner, from family members, or by participating in an organization. These surrounding supporting elements helped to create security and meaningfulness, despite the adversities of life.
“She [my wife] was valuable to me… in all kinds of ways. And I have always encountered love through church, and these things have been very valuable to me.” (Man, ID 19, 85 years).
Some participants highlighted their activities or professional experiences that had provided support in life, while others highlighted important insights or mental attitudes that had helped to form their identities, their inner strengths, or their sense of meaning in life.
“When I grew up […] I had to do as I was told. And with this attitude I have managed.” (Man, ID 6, 76 years)
Alongside the participants’ stories about positive experiences and support throughout life, they also conveyed rich stories about difficulties and adversities in life. These stories were often about being a victim of violence during childhood, for example being subjected to school bullying or experiencing different types of violence in the family.
“I was five years old when I saw my father threaten her [my mother] with a loaded rifle, then she was wedged into a corner and he stood in the middle of the floor. […] Then my childhood ended, that day.” (Woman, ID 8, 73 years).
The participants told their stories about being subjected to violence in the past with such passion and emphasis that it became clear during the interviews how violence – even many years ago – could have just as strong an impact on health as recent events of victimization.
Perceptions of abuse
In the interviews, the participants described all five types of abuse. Patterns of neglect and psychological violence were most prominent in their stories, while economic, physical, and sexual violence were generally less prominent.
Neglect occurred in relation to different helpers that the participants were dependent on, and the neglect was related to a variety of needs. Hygiene needs were neglected when the participants had limited access to help with showering, cleaning or washing services, or clothing. Insufficient assistance with buying food or medication was described in association with staff shortages at the care organizations, which could prevent the older adults from initiating treatment prescribed by a doctor.
Neglected medical needs could involve sloppy or incompetent wound dressing, or when staff often forgot to administer medications. Several stories related to how care staff dismissed the older adults’ medical needs or symptoms, on the incorrect ageist assumption that the symptoms were signs of normal aging. The following quotation was interpreted as an example of age discrimination, and at the same time neglect of medical needs when a woman was refused a regular treatment regime. It was unclear whether the neglect was intentional or not.
“I was in France last year. I went down a mountain, skiing, it was slippery. [I] was going down and then got stuck in a fence, and so I twisted my knee. […] [I waited two days to seek healthcare until I came home from the journey.] And then they tell me ‘Well, because of your age you’ll have to wait for six months [to receive care]’, oh my god, and ‘You’ll have to do physiotherapy and attend to the osteoarthritis school’.” (Woman, ID 18, 69 years).
Examples of social needs being neglected varied in nature. This could involve older adults being frequently forgotten, after staff had said “I’ll be right back” in response to a request for help. Alternatively, social needs could be neglected when older residents at a nursing home were forced to attend social activities that were not in line with the individual’s specific preferences or abilities. A lack of staff continuity could mean that the participants were deprived of steady relationships with other people. In such ways, the participants expressed a lack of a meaningful existence, secondary to the social neglect.
“And the nursing home was so… well, it was so boring, damn it! It was as if a lot of… I don’t know what to call it… zombies [demented people] went around. They didn’t talk. That [living situation] wasn’t stimulating, either for me or for them.” (Man, ID 1, 85 years).
Psychological abuse was often connected to neglect and occurred in healthcare as well as in nursing homes and in family environments. The psychological abuse was often perceived as a means by which to control or manipulate the participant’s actions. This control could be about small matters, like the choice of which food to eat, but it could also be about more important matters like whether or not to request home service. Sometimes the abuser used aggressive speech if the participant did not live up to the abuser’s expectations or demands.
“I’ve talked to him about it [getting home service], but he doesn’t want that, because he thinks it’s too expensive. But I just feel I don’t have energy to do anything. And he says [to me]: ‘You’re so damned lazy.’” (Woman, ID 9, 71 years).
Control was sometimes exerted verbally, but often involved more subtle non-verbal expressions, such as constant surveillance in daily activities, or expressing a non-verbal tone of disapproval if the participant met friends. In one case, a woman had even been prevented from seeing her mother on her death bed:
“So when my mother was dying, they called me [from her town] and told me to come as there was not much time left. […] I’ll come right away I said, I’ll get on the first flight. And then my husband told me I couldn’t go as it was the weekend, and that I should wait until Monday. […] I wanted to say goodbye [to her] anyway, I wanted to be with her. But I never got there in time, they called me on Monday morning and said she was gone. […] And I hate this.” (Woman, ID 7, 66 years).
The controlling behavior often turned into direct threats against the participant from a child or a partner. These threats could be related to physical violence or not being allowed to see their grandchildren anymore. Psychological abuse also occurred in care environments, although the expressions were generally less explicit. In healthcare, just as in family environments, the abuse was perceived as an attempt to control the older participant’s behavior. Often the intent of the staff seemed to be well-meaning, but the expression was perceived aggressive or otherwise negative by the participant. One example was the following situation, where the participant had just completed a cardiac exercise test at the hospital:
“… I had cycled very fast, I was in severe pain and I was lying on the bed. […] and then she [the member of staff] would, at the physician’s request, spray nitro medication under my tongue, which she did and said to me: ‘Shut your mouth and swallow’, but I couldn’t because I was just in cramp… so she says again ‘Shut your mouth and swallow!’ but I still couldn’t do it, and then she turns away and says ‘Well then, forget that shit!’.” (Woman, ID 8, 73 years).
The descriptions of economic abuse that emerged during the interviews were many and rich in character. Sometimes the perception of economic abuse was not primarily associated with the lost financial value, but rather with the feeling of deception after a theft within a relationship of trust, or the feeling of sorrow when the lost item had great sentimental value.
“I felt terrible [when the jewelry was stolen by service staff], and after that I have never again… asked [them] for help. […] Yes, I think a lot about the jewelry being gone… it was a necklace that I had inherited from my mother, and a bracelet…” (Woman, ID 23, 73 years).
Stories about physical abuse during aging were few, but there were more examples of this from earlier in life. Examples of physical violence in old age including a robbery necessitating hospital care, being pushed by an official during a home visit, physical violence from a fellow passenger during transportation services, and one participant being hit by hospital staff.
“I’ve been hit on the head with a pillow. Just because I was cranky, she [the nurse] said. And I didn’t like that… And I said: ‘Now you get out of here, because you shouldn’t be working with people.’ […] [I] think it is frightening when you have to go to a care facility to receive care, and then you get hit! I don’t think it is acceptable.” (Man, ID 6, 76 years).
There were several stories about sexual abuse from earlier in life, but only few from old age. In one case the participant had been recurrently raped within the marriage, but the raping had ended some years before the age of 65. In another case, sexual abuse in contact with healthcare staff had obviously occurred during old age.
“Once, there was a physician that made some – it sounds weird now that I’m 84, I think I was ten years younger then – he really made sexual invitations [to me]. Yes, I think it sounds weird, but I felt very awkward.” (Woman, ID 3, 84 years).
The participants’ stories of sexual abuse expressed clearly feelings of shame and disgust.
Consequences and suffering from the abuse
The abuse that the participants had been exposed to led to various consequences. Psychological consequences included uncomfortable or painful feelings or thoughts that tormented the participant long after the abuse. For example, this could include nervousness, depression, disappointment, or guilt on the part of the abuser or the victim. The intensity of these uncomfortable feelings and thoughts varied over time, with a common gradual decrease as time, ordinary life, or support measures had helped to sooth the remaining discomfort. However, even a long time after the abuse had ended, the painful feelings and thoughts could be brought back by events or conversations, so that the intensity became strong again. Even if the interviews themselves evoked such painful feelings, the participants generally perceived the interviews as positive.
“… Because I sense this, how can somebody just do that? It’s [the painful experience]… Yes, it’s inside me. I try to get rid of it when it comes, but it isn’t so easy, sometimes it just comes and yes, it’s just there.” (Woman, ID 10, 67 years).
The participants described feelings of inferiority or uselessness, even though they tried to convince themselves that such feelings or thoughts were not truthful. Feelings of nervousness and fear increased again when experiencing new threats of abuse, for example when facing a new need for hospital care after previous negative experiences of abuse in healthcare.
“I hate being admitted [to hospital] like this, you don’t know which department you will be admitted to or which staff you will meet. […] You’re always prepared for the worst. You never know who you will meet when you’re admitted… Of course, I’m always on my guard… against a punch or such things.” (Man, ID 6, 76 years).
The fear of being robbed again made the participants vigilant and distrustful toward staff, strangers, and authorities. Lasting harm from abuse could include aches due to internal tension. Although the participant conveyed that the physical symptoms were caused by the abuse or medical errors, such causal relationships or physical consequences sometimes seemed uncertain for the researchers.
Social effects of the abuse could include loneliness, avoiding going outdoors due to fear of violence, or social isolation caused by reduced self-confidence or an abuser limiting their personal freedom. Social effects could also include a reluctance to accept care service due to fear, even though the older adult needed such services. Regardless of whether the abuse was ongoing or in the past, the suffering could be so intense that the person had lost the will to live or even planned to take their own life.
“I wouldn’t be alive if I didn’t have them [the children]. Then [without the children] I’d have been gone [dead] a long time ago. Then, I wouldn’t be alive. I don’t like life that much.” (Woman, ID 7, 66 years).
The participants commonly expressed feelings of abandonment and lack of control, in association with the abuse and their situation. By contrast, a few participants instead conveyed how they continued to defend their autonomy and strove to keep control of the situation through different strategies, despite their limited physical condition due to old age.
Discussion and implications
This aim of this study was to explore experiences of elder abuse among the victims themselves, as their own descriptions can help us to better understand how to develop prevention and interventions against elder abuse. The qualitative analysis resulted in four different themes (vulnerability in old age; experiences from earlier in life; perceptions of abuse; and consequences and suffering from the abuse), which describe different aspects of abuse from the participants’ subjective perspectives. In all, many of the participants’ perceptions of abuse were similar to previous descriptions by third party of elder abuse [ 11 , 21 , 22 ]. Some aspects of the descriptions of elder abuse in this study were also similar to previous descriptions of abuse among younger adults, but other aspects were substantially different [ 30 , 31 , 32 ], as discussed below.
Vulnerability in old age and experiences from earlier in life
Vulnerability to abuse during old age was described as different sorts of dependence on other people, and a lack of autonomy. Due to the effects of normal aging or accumulated diseases, the participants had limited mobility and an increasing need for care in everyday life, which meant dependence on care and vulnerability to abuse from others.
When the participants were exposed to abuse, their ability to defend themselves was also low for the same reasons. In general, this contributed to a submissive attitude toward the helper, together with inner reactions of anger, sorrow, and resignation. These descriptions of vulnerability have similarities with descriptions of vulnerability and powerlessness among younger adult victims of abuse in healthcare and other settings [ 32 , 33 ]. At the same time, the context of the aging body is characteristically different for the older adult, with decreasing capabilities and increasing dependence on care. The participants’ vulnerabilities were very varying and unique to each individual in terms of aging, morbidity, and life experiences.
The descriptions of vulnerability in old age were similar to those recounted by Y Mysyuk, RG Westendorp and J Lindenberg [ 23 ]. Dependence was described as a reciprocal process between the abuser and the victim in Mysyuk et al., something that was not spontaneously conveyed from the participants of this study. Nor did we identify the pattern described in Mysyuk et al., whereby increased weakness or dependence would provoke more violence.
The participants’ stories about previous stages of their life contributed to comprehensive individual pictures of how specific abuse in old age had had impact on their health. It was particularly evident that abuse in the past could have a great impact on health in old age, for example when psychological abuse in childhood had additive or synergistic effects on the perception of elder abuse. This is in line with previous literature on poly-victimization, and underlines that understanding elder abuse presupposes considering previous victimization as well as personality and the victims’ experiences of support, attachment styles, and challenges in life [ 5 , 8 , 34 ]. According to the socio-ecological model of abuse (Fig. 1 ), vulnerability can occur on all levels of an individual’s life, although previous experiences of life mainly correspond to the individual and interpersonal levels for the older adult [ 5 , 9 ]. Previous life experiences are important not only for understanding the individual’s unique vulnerability to abuse, but also for considering the victim’s individual strengths and resources when designing interventions and the prevention of elder abuse [ 35 ]. Hence, our results agree well with previous findings that a life-course perspective is essential when trying to understand the causes and consequences of elder abuse [ 6 , 7 , 8 ]. However, our findings also underline that abuse occurs in a context, and factors on all levels of the socioecological model influence the experience of abuse, e.g., ageist attitudes and dysfunctional care organizations described further on. By paying attention to and validating the older adult’s own life story, staff can indirectly contribute to interventions at community level in accordance with the socio-ecological model, as this level includes how the victim is treated by organizations [ 19 ].
Different kinds of elder abuse, ageism, and perceived causes of elder abuse
Neglect was a common kind of abuse in this study, and there were rich descriptions of this from healthcare settings and long-term care institutions. Not only were physical and medical needs neglected – so, too, were social needs, with consequent intense feelings of abandonment and lack of control among the participants. These descriptions were partly similar to those found in previous studies [ 36 ], although the examples of neglect in this study were often modest in character, meaning potentially mild physical adverse effects in the short term. Nevertheless, also modest shortcomings with hygiene or cleaning could have serious or even life-threatening consequences, as they meant an increased risk of serious wound infections. Ageist attitudes were obvious in different types of abuse, and especially in the descriptions of neglect, in which for example all older adults were treated like objects in a routine way without respect for their individual characters, needs, or preferences.
The psychological abuse occurred in both family and care environments and seemed to correspond to the abusers’ attempts to control the participants’ behaviors. In care environments, the abuse could be a way for staff to control behaviors in line with specific care routines or comfortable forms of work for the staff. The descriptions of psychological abuse in this study were similar to previous descriptions of psychological abuse in younger victims in healthcare and in younger persons in other environments [ 30 , 33 , 37 ].
The participants often added their own personal explanations for the abuse. In addition to descriptions of vulnerability and self-blame, common explanations included individual staff members being unfriendly, care organizations being structurally dysfunctional (with a lack of competence and resources), general greed at all levels of society, and discriminatory (ageist) attitudes and actions leading to neglect. Similar explanations have been described in previous studies, with ageism probably corresponding to all levels of the socio-ecological model [ 11 , 23 , 38 , 39 ]. Some people would perhaps think that structural deficiencies are not relevant to abuse, but the very definition of elder abuse by WHO clarifies that also “lack of appropriate action” in a dysfunctional environment can constitute elder abuse [ 4 ].
A general issue from the analysis of the interviews was whether the WHO definition of elder abuse is too narrow since it limits elder abuse to relations of trust. In several examples there was no identified relation of trust in a reported situation, but rather a “situation of trust” in which the abusive action would best be described as an example of elder abuse. For example, when an older adult is exposed to abuse during transportation services, there would be a situation of trust regardless of whether there are any relations of trust. The older adult would typically be vulnerable in this situation due to the physical limitations of ageing. With a narrow interpretation of the WHO definition, this abuse would dysfunctionally not be classified as elder abuse, although the theoretical framework of elder abuse would fit for an adequate understanding and prevention of the same abuse [ 40 ].
Consequences of the abuse
The participants described consequences of abuse in a way that resembled how consequences of trauma have been previously described among both older and younger adults [ 3 , 30 , 41 ]. Whereas patterns of psychological consequences (with negative thoughts and feelings of shame and fear) were rather like descriptions from previous studies among younger adults, the behavioral consequences were different and related to various social and physical preconditions among the older adults compared to younger adults. Social isolation and loneliness were natural consequences of limited mobility in normal aging or disease, and when abuse also contributed to these limitations the sense of isolation grew particularly strong. When participants chose not to receive home-care services because of the fear of recurrent abuse – despite their needs for assistance – the limiting consequences of abuse were particularly evident. There were also examples from the interviews of how neglect could have serious potential physical consequences, as many of the older adults were less physically able to withstand medical mistreatment.
Implications for the prevention of and intervention into elder abuse
Our findings have several implications for the prevention of and intervention into elder abuse. In terms of the socio-ecological model, preventive measures at community (including hospital level) and societal levels could be to ensure a minimum standard (for example by using legislation or economic incentives) for the care of older adults. According to the participants' voices, higher minimum standards of staff competence and resources would be likely to reduce the tendencies toward neglect, psychological abuse, or other kinds of abuse. Vulnerability and abuse could according to the participants also be prevented through education to care staff about different aspects of elder abuse and about aging. Such educational measures were suggested to promote person-centredness and prevent ageist attitudes, as these attitudes seem to contribute to both the vulnerability and elder abuse [ 39 ]. In addition, support units are also needed to offer individual assistance to victims of elder abuse as the negative consequences are substantial. According to a bifocal ecological approach, the assistance should not only be directed to the victim for an effective prevention but also to the perpetrator [ 42 ]. However, an important principle should be to adapt the preventive measures to the individual, as both vulnerability and abuse perceptions vary significantly according to the individual’s unique biopsychosocial conditions and experiences from earlier life. This also underlines the need for a life-course perspective on elder abuse [ 34 , 43 ].
In order to minimize bias introduced by the researchers’ preconceptions and instead promote reflexivity, four researchers with different backgrounds have cooperated in the study. Three of the authors work as physicians within geriatrics and psychiatry, while the fourth author works with research, mostly outside hospital environments.
The fact that the sample was selected from inpatient care could be regarded as a disadvantage, as some older adults might have had too little energy to participate actively in interviews while suffering from an acute illness with associated physical exhaustion. On the other hand, the decision to recruit participants from inpatient care meant certain advantages, for example offering the participants a secure context for the interviews while their home or other environments might have been less secure, or more easily controlled by an abuser.
The results are likely to be transferable to older adults in Sweden but should be transferred with caution to countries with other cultures or societal structures.
This is one of few studies to date in which qualitative interviews have been used to explore experiences of elder abuse among the victims themselves. Their stories had similarities with both previous third-party descriptions of elder abuse and previous descriptions of abuse among younger adults. There were also substantial differences, with the consequence that elder abuse needs to be understood and managed by partly different means compared to abuse among younger adults. Vulnerability to elder abuse is often associated with an individual mix of the aging body, illnesses, and a dependence on secondary help. A life-course perspective considering experiences from the individual’s past would be beneficial when designing support for older victims, as such experiences are important to the degree of suffering and disability that the victim develops in relation to elder abuse. Prevention ought to include individually tailored help or support to reduce vulnerability, specific education, and ensuring an acceptable minimum standard of care for older adults in general [ 14 ].
Availability of data and materials
The datasets generated and analyzed during the current study are not publicly available and are not available from the corresponding author on request due to reasons concerning participant privacy and confidentiality.
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Open access funding provided by Linköping University. This work was supported by the Swedish Crime Victim Fund, grants no. 3322/2017, 2944/2018, and 03384/2019. The funding source had no involvement in the study design, data collection, analysis, interpretation of the data nor in writing the manuscript.
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Department of Acute Internal Medicine and Geriatrics and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
Mikael Ludvigsson, Nicolina Wiklund & Johanna Simmons
Department of Psychiatry and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
Department of Health and Caring Sciences, Faculty of Health and Life Sciences, Linnaeus University, Kalmar, Sweden
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All authors contributed to the design of the study. JS, NW and ML performed the interviews and performed proofreading of transcripts. Six interviews were coded separately and were then discussed together by all the authors. For the remaining interviews, the coding and development of tentative subcategories and themes were carried out by ML and JS. Tentative themes/subthemes were then discussed and revised by all the authors together. ML wrote the first draft of the manuscript, and all authors contributed to and approved the final manuscript.
Correspondence to Mikael Ludvigsson .
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The study was approved by the Regional Ethics Review Board in Linköping, Sweden (2017/181–31; 2017/564–32) and was conducted in accordance with the principles of the Declaration of Helsinki. All participants gave written informed consent at the time of participation.
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Ludvigsson, M., Wiklund, N., Swahnberg, K. et al. Experiences of elder abuse: a qualitative study among victims in Sweden. BMC Geriatr 22 , 256 (2022). https://doi.org/10.1186/s12877-022-02933-8
Received : 12 October 2021
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DOI : https://doi.org/10.1186/s12877-022-02933-8
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Elder Abuse Research: A Systematic Review
Jeanette m. daly.
Department of Family Medicine, Carver College of Medicine, University of Iowa
Mary L. Merchant
Gerald j. jogerst.
A systematic review of elder abuse research has not been conducted across disciplines. The purpose of this research was to provide a systematic review of and assign an evidence grade to the research articles on elder abuse. Sixteen healthcare and criminal justice literature databases were searched. The literature review was of English-language publications reporting research on abuse of people aged 55 years and older, from any country. Titles, abstracts, and publications were retrieved from 16 databases and were reviewed by at least 2 independent readers who graded each from A (evidence of well-designed meta-analysis) to D (evidence from expert opinion or multiple case reports) on the quality of the evidence gained from the research. Of 6,676 titles identified in the search, 1,700 publications met inclusion criteria. Omitting duplicates from the 1,700 publications, 590 publications were annotated and graded. No elder abuse research publication was given an A grade. Fourteen publications were given a B grade (controlled trials), 483 were given a C grade (observational studies), and 93 were given a D grade (opinion or multiple case reports). Of the 590 publications, 492 were quantitative studies, 78 were qualitative studies, and 20 were case studies. Little evidence is available that supports any intervention to prevent elder abuse. Financial support for elder abuse research is needed along with more rigorous research trials.
Elder mistreatment “refers to (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 , p. 3). The World Health Organization defines abuse as “a single or repeated act or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person” (2009, p. 6). Types of elder mistreatment include abandonment, emotional abuse, financial or material exploitation, neglect, physical abuse and sexual abuse ( Daly & Jogerst, 2001 ). For the purpose of this study, the term elder abuse will be used as the all-inclusive term, as it is the main term listed in all states’ and the District of Columbia’s adult protective services-related statutes. Elder abuse is also the term used as the medical subject heading for literature searches by the National Library of Medicine (NLM). The NLM defines elder abuse as emotional, nutritional, or physical maltreatment of the older person generally by family members or by institutional personnel.
The recent 2003 National Research Council’s report on elder abuse research stated, “no efforts have yet been made to develop, implement, and evaluate interventions based on scientifically grounded hypotheses about the causes of elder mistreatment, and no systematic research has been conducted to measure and evaluate the effects of existing interventions” ( National Research Council, 2003 , p. 121). The purpose of this study was to provide a systematic review of and assign an evidence grade to the research articles on elder abuse.
To determine the current status and quality of elder abuse research, a comprehensive review of the health sciences literature was performed, and each publication was graded. All literature searches were conducted from inception of each index through December 31, 2008. Elder abuse research publication inclusion criteria were: English-language articles reporting completed research on abuse of people aged 55 years and older, from any country. An expert reference librarian conducted the electronic search with input from study investigators. Sixteen databases were searched: AgeLine Database; American Theological Library Association (ATLA) Religion Database with AtlaSerials; Cochrane Database of Systematic Reviews; Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus; Education Resources Information Center (ERIC); Index to Legal Periodicals; LegalTrac; LexisNexis Academic; LexisNexis Government Periodicals Index; National Criminal Justice Reference Service (NCJRS) Abstracts Database; PsycINFO; PubMed, which included MEDLINE; Social Work Abstracts; and the Web of Science three indexes: Social Sciences Citation Index (SSCI), Science Citation Index Expanded (SCI-EXPANDED), and the Arts & Humanities Citation Index (A & HCI). The databases were searched using combinations of the following keywords: abuse, aged, elder, elder abuse, neglect, and exploitation. In addition, two other mechanisms were used to retrieve the elder abuse research: a manual search of the reference list of publications dated prior to 1990 and a reference search of elder abuse reviews or annotations.
From the 16 database searches, 6,676 citations and were retrieved (See Table 1 ). Each citation was reviewed by one of the investigators. If an abstract was not available and the title indicated it could be research, the publication was viewed online or retrieved from a library. From the 6,676 citations, 1,700 were deemed to be elder abuse research. All selected articles were published in peer-reviewed journals and contained original data on elder abuse. Many citations were overlapping, as manuscripts are indexed in duplicate databases. Single case reports were omitted from the review.
Literature Databases Searched, Number of Citations and Research Publications Reviewed.
The search for elder abuse reviews or annotations resulted in seven publications in which the reference lists were reviewed ( Cloke, 1983 ; Giordano & Giordano, 1984 ; Johnson, O’Brien, & Hudson, 1985 ; National Clearinghouse on Family Violence, 1983 ; Moore & Thompson, 1987 ; Schlesinger & Schlesinger, 1988 ; Spencer, Ashfield, Vanderbijl, & Bischof, 1996 ). The reference list of those citations were reviewed to determine if there were additional elder abuse research articles available, not already found in the database citation review. Most of these reviews were of books, book chapters, conference proceedings, Internet sites, non-research articles, research articles and reports. The reference lists showed no new research articles beyond those found in the indexes.
Each research study was critically reviewed, annotated, and assigned an evidence grade based upon the type and strength of evidence from the research. Different kinds of research vary in terms of methodological validity, how results are presented and how they are understood by individuals. The grading schema used to make recommendations for the elder abuse research publications were based on the level of evidence and grade for recommendations by the Centre for Evidence Based Medicine at The University of Oxford and adapted for this project ( Centre for Evidence Based Medicine, 2009 ). The following grading levels were used:
- A = evidence from well-designed meta-analysis
- B = evidence from well-designed controlled trials, both randomized and nonrandomized, with results that consistently support a specific action (e.g., assessment, intervention or treatment).
- C = evidence from observational studies (e.g., correlational, descriptive studies) or controlled trials with inconsistent results.
- D = evidence from expert opinion or multiple case reports.
Nonrandomized controlled study designs can include non-randomized controlled trial, controlled before-and-after study, interrupted time series study. After each article was reviewed, annotated, and graded by an investigator, a second investigator reviewed the annotation and grade. Grades were identical for 539 (91%) of the studies. Consensus between the two reviewers was reached on the remaining 51 (9%) publications after re-review of the publications’ methods in question. Kappa was 0.7466 (95% CI (0.6819, 0.8114)), indicating substantial interrater agreement.
Once duplicates were deleted from the 1,700 publications, 590 publications were annotated and graded. No elder abuse research publication was given an A grade. Fourteen publications were given a B grade, 483 were given a C grade, and 93 were given a D grade. Of the 590 publications, 492 were quantitative studies, 78 were qualitative studies, and 20 were case studies. Studies were conducted in 32 countries; 374 studies were conducted in the U.S., 51 in Canada, and 20 studies in Australia. The 590 articles were published by 203 different journals with the following journals having the most publications: Journal of Elder Abuse & Neglect , 171 publications; The Gerontologist , 35 publications; the Journal of Gerontological Social Work , 21 publications; and the Journal of the American Geriatrics Society , 19 publications. Fifteen journals published 324 (55%) of the publications.
Fifty-five (9%) of the publications were published from 1975 through 1989, 203 (34%) were published in the 1990s, and the most 332 (56%) publications from 2000 to 2008 (See Figure 1 ). The earliest research publication found was a case study of 30 patients living in squalor referred to a geriatric in-patient unit. A battery of tests were conducted including descriptions of the living environment, family, nutrition, and finances with a resulting conclusion that severe neglect in old age is a syndrome and that care can only be provided with the patient’s permission ( Clark, Mankikar, & Gray, 1975 ). The next earliest, an exploratory study was conducted to determine the incidence and nature of abuse in cases accepted at a chronic illness center. In a 12-month period, 39 cases of abuse were identified from 404 cases. From those 39 cases, 51% were physically disabled, 10% had hearing or visual impairment, 18% were incontinent, and 41% were cognitively impaired. Those most common type of abuse was physical (7%), psychological and material (5%), and violation of rights (2%) and in 90% of the cases the perpetrator was a relative. Unfortunately, 26% of the victims were resigned to the situation, 33% denied the abuse, and 21% were withdrawn ( Lau & Kosberg, 1979 ).
Elder Abuse Research Articles Published by Year.
Fourteen publications were grade B, experimental with pretest-post test and factorial designs, mainly published in education journals ( Brownell & Heiser, 2006 ; Desy & Prohaska, 2008 ; Golding, Yozwiak, Kinstle, & Marsil, 2005 ; Goodridge, Johnston, & Thomson, 1997 ; Hsieh, Wang, Yen, & Liu, 2008 ; Leedahl & Ferraro, 2007 ; Pillemer & Hudson, 1993 ; Nusbaum, Mistretta, & Wegner, 2007 ; Reay & Browne, 2002 ; Richardson, Kitchen, & Living, 2004 ; Richardson, Kitchen, & Living, 2002 ; Uva & Guttman, 1996 ; Vinton, 1993 ; Wilbur, 1991 ). In these studies, subjects were both randomized and nonrandomized. Study objectives varied from examining the effectiveness of abuse prevention training programs, psycho-social support groups, a daily money management program, and an anger management program with education (See Table 2 ). Two of the studies implemented intervention for victims of abuse ( Brownell & Heiser, 2006 ; Wilbur, 1991 ), and one implemented interventions for perpetrators of abuse ( Reay & Browne, 2002 ). Most of the studies were targeted to healthcare professionals ( Desy & Prohaska, 2008 ; Goodridge, Johnston, & Thomson, 1997 ; Hsieh, Wang, Yen, & Liu, 2008 ; Pillemer & Hudson, 1993 ; Richardson, Kitchen, & Living, 2004 ; Richardson, Kitchen, & Living, 2002 ; Uva & Guttman, 1996 ; Vinton, 1993 ). Two of the publications were for the same study and intervention, but had different outcomes ( Richardson, Kitchen, & Living, 2004 ; Richardson, Kitchen, & Living, 2002 ). Nine of the studies were conducted in the U.S. ( Brownell & Heiser, 2006 ; Desy & Prohaska, 2008 ; Golding, Yozwiak, Kinstle, & Marsil, 2005 ; Leedahl & Ferraro, 2007 ; Pillemer & Hudson, 1993 ; Nusbaum, Mistretta, & Wegner, 2007 ; Uva & Guttman, 1996 ; Vinton, 1993 ; Wilbur, 1991 ), 3 in England ( Reay & Browne, 2002 ; Richardson, Kitchen, & Living, 2004 ; Richardson, Kitchen, & Living, 2002 ), 1 in Canada ( Goodridge, Johnston, Thomson, 1997 ), and 1 in Taiwan ( Hsieh, Wang, Yen, & Liu, 2008 ).
Elder Abuse Research Intervention Studies.
Forty-three first authors have published more than 3 publications, for a total of 233 (39%) publications. Twenty-two first authors have published 5 or more publications, with a total of 161 publications. The more highly published researchers are from the disciplines of criminology, medicine, nursing, political science, psychology, public administration and public affairs, public health, social welfare policy, sociology, and social work.
During the grading process, studies were categorized by the following concepts: adult protective services/area agency on aging, caregiver, case study, definitions, education, instruments, interventions, legislation, nursing home, prevalence, qualitative, research review, theory and emergency department. A summary of the prevalence research indicates that over time similar methodological issues remain the same.
Elder Abuse Prevalence
Elder abuse prevalence has been estimated in different settings and in these studies various methods for data collection were used. A sample of various studies that depict elder abuse prevalence is presented from major epidemiological studies, agency reports, healthcare professionals, caregivers and family, and medical record review. These studies range from the earliest prevalence study in 1979 ( Lau & Kosberg, 1979 ) to some of the latest studies in 2008 ( Laumann, Leitsch, & Waite, 2008 ; Phua, Ng, & Seow, 2008 ). Eight major epidemiological studies estimated the prevalence of elder abuse in different countries. Overall prevalence rates of elder abuse have varied considerably across studies, from 2.6% in United Kingdom ( Manthorpe, Biggs, McCreadie, et al., 2007 ), 3.2% in Boston ( Pillemer & Finkelhor, 1988 ), 4% in Canada ( Podnieks, 1992 ), 5.4% in Ahtari, Finland (Kivela, Kongas-Saviaro, Kesti, et al., 1992), 5.6% in Amsterdam ( Comijs, Post, Smit, et al., 1998 ), 6.3% in a district of Seoul ( Oh, Kim, & Kim, 2006 ), 8.8% in Britain ( Ogg & Bennett, 1992 ), to 14% in Chennai, India ( Chokkanathan & Lee, 2005 ). Rates were calculated for persons 65 years and older in all the studies except for Britain, where the age was 60 years and the United Kingdom, where the age was 66 years.
Other prevalence estimates have been generated from the annual state reports from protective services agencies, providing actual cases of elder abuse based on those reported. From 1999 APS annual reports, 242,430 recorded investigations of domestic elder abuse in 47 states were found; that is, 5.5 investigations per 1,000 elders. Also reported were 102,879 substantiations, or 2.7 substantiations per 1,000 elders ( Jogerst, Daly, Brinig, et al., 2003 ). State APS administrators find it difficult to answer surveys about elder mistreatment aggregated at the state level, as evidenced by the fact that not all states are reporting ( Jogerst, Daly, Brinig, et al., 2003 ; Daly & Jogerst, 2005 ).
In a convenience sample where 228 professionals were interviewed, 60% reported dealing with passive abuse, and 8% dealt with abuse leading to serious injury ( Hickey & Douglass, 1981 ). In a survey mailed to more than 1,000 health care organizations in Western Australia, the 340 respondents reported 253 suspected cases of abuse, suggesting an estimated prevalence rate of 0.58 percent ( Boldy, Horner, Crouchley, et al., 2005 ). In Sweden, district nurses described the patterns of abuse of elderly persons living independently in their homes. Eighteen of the 153 nurses reported 30 cases of elder abuse as defined by the elderly persons over a six-month time period. The most commonly reported type of abuse was psychological abuse followed by isolation, physical abuse, neglect and material abuse ( Saveman, Hallberg, Norberg, et al., 1993 ).
When caregivers of elder patients in respite care were interviewed about physical and verbal abuse, and neglect, 23 (45 percent) of 51 carers confessed to some type of abuse, with verbal abuse the most frequent type ( Homer & Gilleard, 1990 ). Australian home health caseworkers were surveyed to determine one-month prevalence from their respective caseloads. Of 598 clients, 33 (5.5 percent) had experienced some form of abuse ( Cupitt, 1997 ).
Elder abuse prevalence in nursing homes is difficult to estimate. Through a random sample survey of 577 nursing home nurses and nursing assistants, 36% had witnessed an incident of physical abuse in the preceding year, and 81% had observed an incident of psychological abuse. Ten percent of the respondents admitted to committing one or more abusive acts themselves ( Pillemer & Moore, 1989 ). Of 27 randomly selected nursing assistants from 3 nursing homes, 93% reported they had seen or heard of residents being mistreated, abused and neglected ( Mercer, Heacock, & Beck, 1993 ). With 90% of the administrators and directors of nursing reporting from Iowa’s 409 stand-alone nursing homes, 18.4 abuse events per 1,000 nursing home residents were reported to state authorities in a year with 5.2 of those reports substantiated ( Jogerst, Daly, Dawson, et al., 2006 ).
To understand the current state of elder abuse research, a rigorous systematic review of the literature was conducted. Until now, the actual state of elder abuse research was unknown. In an attempt to find all elder abuse research, 16 databases were searched, and 590 research publications were found. Contradicting the National Research Councils conclusion of no intervention studies being conducted, this study found 14 efforts to develop, implement, and evaluate interventions based on scientifically grounded hypotheses to measure and evaluate the effects of existing interventions on the prevention of elder abuse. The first of the intervention studies was conducted in 1991 ( Wilbur, 1991 ) and the latest in 2008 ( Desy & Prohaska, 2008 ; Hsieh, Wang, Yen, & Liu, 2008 ).
The education interventions focused on caregivers of elders and ranged from one hour to eight hours taught by different methods, such as one-to-one instruction, or education in a classroom, or education with group support. Outcomes were different by study and had some significant improvements regardless of the length of the education session. The outcome measures were different across studies and cannot be compared. Iowa is the only state that requires all mandatory reporters to be trained on dependent adult abuse within 6 months of employment and every 5 years thereafter. Unfortunately, the required education did not change the investigation of findings of abuse in Iowa. Required dependent adult abuse education for mandatory reporters has not increased the domestic investigation or substantiation rates for elder abuse ( Jogerst, Daly, Dawson, et al., 2003 ).
The breadth of journals and indexes housing elder abuse research demonstrates the magnitude of this social and criminal problem as well as the interdisciplinary efforts to identify the victims, causes of abuse, and interventions to prevent it. A small portion of this research has focused on finding interventions to facilitate the prevention of abuse. The 14 intervention studies generated three types of solutions; education of caregivers, adult protective service workers, and health care personnel; support group meetings; and a daily money management program. Prevention of elder abuse will require a comprehensive approach involving a multifaceted intervention including multiple sectors of society. Other appropriate and potential interventions for preventing elder abuse that haven’t been tested in a rigorous trial include legislation, respite programs, social support, batterer interventions such as, anger management, cognitive therapy, and couples therapy.
Prevalence studies are conducted in different settings, with different types and definitions of elder abuse, and various instruments to measure the abuse. With such a variation, it is difficult to compare results and comparisons should only be made across the same type of study. For example, if the prevalence of elder abuse is determined in the emergency room that is very different from an epidemiological study conducted in the Boston area.
From this review, it is evident a national system of standardized elder abuse data collection is paramount. A standardized elder abuse system would define essential data elements that at a minimum includes victim and perpetrator name, address, age, gender, race, type of abuse, and time, date, and location of the alleged incident and at a maximum would link the social and criminal system’s databases. The extent of overlap from the Medicaid Fraud Reports, the National Ombudsman Reporting System, the adult protective services/elder services annual reports, and the federal nursing facility Automated Survey Processing Environment Complaints/Incidents Tracking System is unknown.
This review has several limitations. Though the publications were graded, that is the only criteria used to assess the quality of the studies. Other criteria, such as sufficient description of study objective, appropriate study design, satisfactory response rate, or adequacy of sample size were not evaluated. Although we conducted a comprehensive search, it is possible we missed a relevant study. This was a comprehensive review of elder abuse research printed in journals, not a meta-analysis.
This review describes the state of current elder abuse research which is comprised primarily of descriptive, observational, case studies, no meta-analyses, and a few intervention trials. In a field that is young in research publications, family medicine, researchers in that field published 790 articles in 2003, compared to 38 elder abuse research articles in the same year ( Pathman, Viera, & Newton, 2008 ). The evidence is clear, elder abuse research is minimal and difficult to discern across disciplines The U.S. population depends on federal agencies to promote scientific research and to facilitate the development of science-based policies. Lack of funding efforts directed towards elder abuse has weakened the support for these studies. Few National Institutes of Health program announcements or requests for applications have been released with a focus on elder abuse.
The 590 annotated publications can be found on the Department of Family Medicine, Carver College of Medicine web site at www.uihealthcare.com/depts/med/familymedicine/index.html . This site is searchable by publication grade, country, or any search term.
This research presents key findings, scope and limitations of elder abuse research to date. It is a valuable source of information for both active and developing scholars in the field both as a review of the literature and as a gap analysis with implications for further study. The findings are also significant as a guide for research agenda building for government and foundation funding sources. Little evidence is available that supports any intervention to prevent elder abuse. A few intervention trials have been conducted to facilitate the performance of health care professionals and reduce their abuse while at work, with success demonstrated in most studies. Funding for elder abuse research is warranted and more rigorous elder abuse research and more investigators are needed.
This work was supported by a grant from the National Institutes of Health, National Library of Medicine 5 G12 LM008625.
Jeanette M. Daly, Department of Family Medicine, Carver College of Medicine, University of Iowa.
Mary L. Merchant, Department of Family Medicine, Carver College of Medicine, University of Iowa.
Gerald J. Jogerst, Department of Family Medicine, Carver College of Medicine, University of Iowa.
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89 Elder Abuse Essay Topic Ideas & Examples
🏆 best elder abuse topic ideas & essay examples, ✅ good essay topics on elder abuse, 📑 interesting topics to write about elder abuse, ❓ questions about elder abuse, 💯 free elder abuse essay topic generator.
- Community and Domestic Violence: Elder Abuse In addition, the fact the elderly people cannot defend themselves because of the physical frailty that they encounter, they will experience most of the elderly abuse.
- Domestic Violence and Elderly Abuse- A Policy Statement Though this figure has been changing with the change in the method of survey that was conducted and the nature of samples that were taken during the research process, it is widely accepted fact that […]
- Financial Abuse of the Elderly When elderly abuse is mentioned, most people think that sexual or physical harassment on the elderly is the only form of mistreatment that qualifies to be abuse.
- Curbing Elder Abuse and Neglect The contemporary evaluation studies of the elderly citizens’ emotional stability prove that there is a consistent percentage of offensive treatment towards the seniors both in the family environments and asylums.
- Child and Elder Abuse: Is It Really Different? The people committing the crime of child abuse are usually people known and trusted by the children as it is in this case.
- The Issue of Elder Abuse in the US The purpose of this paper is to analyze the problem of elder abuse in America based on the data from the United States.
- Elder Abuse and Its Consequences The level of abuse being directed towards elderly people has sort of been under the radar but organizations such as National Centre on Elderly Abuse plus countless others have brought this issue to the forefront […]
- Learning to Detect and Report Elder Abuse The members of the society should be aware of the mechanisms of identifying an elderly individual who is a victim of violence and abuse.
- Elder Abuse Problems: Implementing Health Policies A number of organizations and individuals are already involved in elderly justice, which is the collective action of restoring dignitary to senior citizen care in the country.
- Advocacy in Action: Elderly Abuse and Impact on Society The research suggests that family members and caregivers are the main abusers of the elderly population and, therefore, there should be specific programs that can contribute to enhancing the quality of life of senior members […]
- The Elderly Abuse: Physical and Psychological Aspects It is essential to understand these mistreatments’ similarities and differences and the intervention measures to stop or prevent them. Physical abuse causes bodily harm and can result in impairment, pain, or injury, such as broken […]
- P-Plan Proposal: Youth, Adult and Elderly Abuse To ensure that equality and sanity is maintained, the government normally has some set rules and regulations that have to be adhered to.
- Dependent Adult and Elderly Neglect and Abuse Dependent elderly are people who need assistance to do daily activities and to protect themselves. They also include sick adults who are in hospitals all the time.
- Self-Determination of the Elderly Needs and Elder Abuse Thus, the Petrakis family case demonstrates that Magda is an older individual whose needs should have been assessed according to seven domains, and it is necessary to offer additional questions to investigate the situation.
- Domestic Violence, Child Abuse, or Elder Abuse In every health facility, a nurse who notices the signs of abuse and domestic violence must report them to the relevant authorities.
- The Issue of Elder Abuse and Its Management This complex problem has to be addressed on a systemic level, including interventions and solutions to moderate the behavior of both the abusers and the abused, encourage recuperative efforts, and offer mechanisms for reporting abuse.
- Elder Abuse: Learn the Signs and Break the Silence This is an act of emotional abuse and material exploitation by depriving the elderly women of communication, the man tries to get what he wants.
- The Issue of Elder Abuse and Violence In terms of the public’s perception of elder abuse, it is feasible to state that the opinions and problems among the general society differ from, for example, the specialists within the field of healthcare.
- Elder Abuse Under Sociological Analysis The most prominent kind of elder abuse is abuse by omission, which means that the caretaker fails to provide the elder with necessities.
- The Elder Abuse in the Russian Culture
- The Harry and Jeanette Weinberg Center for Elder Justice: Elder Abuse Prevention Program
- The Impact of Elder Abuse on a Growing Senior Veteran Population
- Elder Abuse Policy: Considerations in Research and Legislation
- The High Prevalence of Depression and Dementia in Elder Abuse and Neglect
- Prevalence Patterns and Associated Factors of Elder Abuse in an Urban Slum of Eastern India
- Reducing Elder Abuse in Ireland and Germany: Elder Care Programs in Ireland and Germany
- Elder Abuse and Elder Financial Exploitation Statutes
- Legal Help for Different Types of Elder Abuse
- Elderly Abuse, Teenage Pregnancy, and Proposed Solutions to These Two Family Problems
- A Feminist Perspective on Gender and Elder Abuse
- Abuse and Neglect of the Frail Elderly at Home
- Educational Nursing Strategies: Prevention of Elder Abuse and Neglect
- Elder Abuse Issues in Canada: The Most Common Form Is Financial Abuse
- Case of Elderly Abuse: The Alzheimer’s Care of Commerce
- Social Isolation as a Risk Factor for Elder Abuse
- Elder Abuse Is the Main Issue Affecting Around the World
- The Effects of Alcohol Abuse on the Elderly Population
- Social Work Response to Elder Abuse in Uganda
- Enhancing the Justice System’s Response to Elder Abuse.
- Sexual Elder Abuse: Dementia, Alzheimer’s, or Other Cognitive Disabilities
- Elder Abuse Due to Neglect: Trends and Consequences
- The Issue of Elder Abuse and Safeguarding in the UK
- Emotional Elder Abuse: The Most Frequently Reported Type
- Assisted Suicide and Elder Abuse: A Sense of Guilt and Fright Becoming a Burden
- Elder Abuse: Need for Educational Interventions to Create Public
- Elder Abuse and Living Arrangements in Late Adulthood
- California Has the Highest Rate of Elder Abuse
- Barriers to Obtaining Statistics on Elder Abuse
- Abandonment as Elder Abuse: Leaving Without Any Formal Arrangement
- Elder Abuse and Neglect in Latino Families
- Elder Abuse Victimization Patterns: Determining Latent Classes With Victims’ Characteristics
- The Role of the Criminal Justice System in Elder Abuse Cases
- The Seniors’ Rights and Elder Abuse Protection Act
- Using Latent Class Analysis to Identify Profiles of Elder Abuse Perpetrators
- Examination of Explanations for the Occurrence of Elder Abuse
- Elder Abuse in Nursing Homes: Prevention and Resolution Strategies and Barriers
- Helping Prevent Elder Abuse Globally Through the Use of Social Media
- The Most Frequent Perpetrators of Elder Abuse
- Elder Abuse Phenomenon Correlating Relationship to Elder Mortality
- What Are the Most Common Types of Elder Abuse?
- Where Does Elder Abuse Happen the Most?
- Is Gender a Risk Factor for Elder Abuse?
- What Are the Signs of Elder Abuse?
- How Big of a Problem Is Elder Abuse in the US?
- What Are the Major Factors of Elder Abuse?
- Why Are Females More Likely to Be Victims of Elder Abuse?
- How to Prevent Elder Abuse in Nursing Homes?
- What Is the Fastest Form of Elder Abuse?
- Which Type of Elder Abuse Is the Most Unreported?
- Are Statistically Most Victims of Elder Abuse Female?
- What Is the Side Effect of Elder Abuse?
- Who Is the Most Common Perpetrator of Elder Abuse?
- Is Elder Abuse a Crime in the United States?
- What Individuals Are at Higher Risk of Being a Victim of Elder Abuse?
- Why Is It Important to Prevent Elder Abuse?
- What Percent of Elder Abuse Is Caused by Family Members?
- Is There Mandatory Reporting for Elder Abuse in the US?
- Why Is Elder Abuse Becoming More Prevalent in the United States?
- What Is One Reason That Elder Abuse Can Be Difficult to Identify?
- How to Prove Elder Abuse in California?
- What Are the Negative Effects of Elder Abuse?
- How Long Do You Go to Jail for Elder Abuse in California?
- What Can Be Done to End Elder Abuse?
- Is Elder Abuse a Social Issue Worldwide?
- What Increases the Chance of Elder Abuse?
- How Big Is the Problem of Elder Abuse in America?
- What Is the Role Theory of Elder Abuse?
- How Does Culture Affect Elder Abuse?
- What Are the Profiles of the Most Common and Least Common Perpetrators of Elder Abuse?
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Elder abuse: What research says about prevalence, assessment and prevention
We’ve gathered and summarized several relevant studies on elder abuse, including research in the context of the COVID-19 pandemic.
Republish this article
This work is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License .
by Sari Boren, The Journalist's Resource July 16, 2020
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Abuse of people age 60 and older is widespread, research shows. According to a 2017 study in The Lancet Global Health , “elder abuse seems to affect 1 in 6 older adults worldwide, which is roughly 141 million people.”
Elder abuse takes many forms. A 2015 review article in The New England Journal of Medicine explains that research on elder abuse generally addresses these five categories: “physical abuse, or acts carried out with the intention to cause physical pain or injury; psychological or verbal abuse, defined as acts carried out with the aim of causing emotional pain or injury; sexual abuse, defined as nonconsensual sexual contact of any kind; financial exploitation, involving the misappropriation of an older person’s money or property; and neglect, or the failure of a designated caregiver to meet the needs of a dependent older person.”
Take for example a 2014 study in the Journal of General Internal Medicine , in which researchers studied nearly 4,000 older residents of New York state. They found that financial abuse afflicted nearly 5% of them during their lifetime, with Black people at higher risk. “If a new disease entity were discovered that afflicted nearly one in 20 adults over their older lifetimes and differentially struck our most vulnerable subpopulations, a public health crisis would likely be declared,” the authors write. “Our data suggest that financial exploitation of older adults is such a phenomenon.”
But as prevalent as elder abuse is, it also goes widely unreported.
A 2018 article in Clinics in Geriatric Medicine , citing research from a 2011 report from the New York City Department for Aging, suggests that about only 1 in 24 cases of elder abuse is identified and reported to social service or legal authorities. The recognition, identification and regulation of elder abuse is complicated by the self-determination granted adults; in other words, while children are mostly seen as a vulnerable population requiring protection, there’s less oversight with vulnerable older adults.
In the past few years federal legislation designed to protect older Americans has passed or been proposed. The Elder Abuse Prevention and Prosecution Act of 2017 , signed into law in October of that year, increased data collection, information sharing, training for federal prosecutors and investigators and penalties for criminal acts for elder abuse. It also established coordinator positions at the Federal Trade Commission and the Department of Justice.
In recent months, the U.S. Senate’s Special Senate Committee on Aging has called attention to increased risk of elder abuse during the COVID-19 pandemic. In May, Sens. Susan Collins, R-Maine; Bob Menendez, D-NJ; and Chuck Grassley, R-Iowa, introduced the “Promoting Alzheimer’s Awareness to Prevent Elder Abuse Act.” That bill builds on the Elder Abuse Prevention and Prosecution Act of 2017 and is paired with companion legislation in the House. When introducing the bill, Sen. Collins said, “During the COVID-19 pandemic, there may be increased risk for elder abuse, including elder financial exploitation. Our bipartisan bill would help to ensure that the frontline professionals who are leading the charge against elder abuse have the training needed to respond to cases where the victim or a witness has Alzheimer’s disease or other forms of dementia.”
Health care providers who work with elderly patients also warn that the pandemic has exacerbated some of the risk factors for elder abuse, for both victims and perpetrators. The COVID-19 stay-at-home orders/recommendations that are meant to keep older people physically safe from the virus may create conditions for abuse. Older adults are now more likely to be isolated and out of sight, for example, making potential abuse harder to detect. Perpetrators, including family members, who experience increased personal or financial stress caused by the pandemic may be more likely to commit abuse.
In addition, there has been increasing ageism rhetoric in the United States during the COVID-19 pandemic, devaluing the lives of older adults, note the authors of a recent letter to the editor in the Journal of the American Geriatrics Society . To combat ageism in our culture, they suggest “increasing representation of older people with decision-making power in public and private sectors.”
To help journalists cover stories of elder abuse, we’ve gathered and summarized several relevant studies, including a recent article on abuse in the context of the COVID-19 pandemic. We also have compiled information on current and pending legislation on the topic, an introduction to a specific type of elder abuse called guardianship abuse, and additional resources for in-depth reporting.
A note on the limitations of data in many studies of elder abuse: Data is often self-reported, depending on the victim to divulge the abuse. Shame of abuse and/or the vulnerable position of older people who may rely on abusers for daily living needs often make older adults less likely to report abuse, leading to underreporting. And most studies exclude participants with dementia or cognitive impairment, even though older people with those issues experience abuse. According to Professor Pamela Teaster , director of the Center for Gerontology at Virginia Tech, these exclusions occur because self-reporting by people with dementia may be unreliable and because of protections for people with dementia regarding research. In an e-mail to Journalist’s Resource she explained, “We have to be very careful because, depending on the degree of the dementia, they may be unable to consent to participate in research.”
Elder Abuse Mark S. Lachs and Karl A. Pillemer. The New England Journal of Medicine , November 2015
The authors of this highly cited paper estimate that across the U.S., approximately 10% of older adults not living in care facilities are victims of abuse. “Thus, a busy physician caring for older adults will encounter a victim of such abuse on a frequent basis, regardless of whether the physician recognizes the abuse,” they write.
People with dementia are at especially high risk, and women are at higher risk than men, the authors note. Those at the younger end of the age group, the so-called “young old,” also have increased risks, as they more often live with the most likely abusers: a partner or adult children.
To help physicians identify elder abuse, the authors create a detailed breakdown of types of elder abuse (physical, verbal/psychological, sexual, financial, neglect) along with ways that abuse manifests itself during physical exams (for example, bone fractures may be a manifestation of physical abuse).
Assessment strategies for physicians include interviewing potential victims separately and alone and recognizing that mental illness resistant to treatment may have its source in emotional abuse. The authors also note that signs of neglect and financial abuse may be more subtle than those of physical abuse (e.g., weight loss and failure to keep appointments or fill prescriptions). Other assessments are specific to the abuse manifestations, such as determining if fractures are from abuse or falls/accidents. Physicians are cautioned that interviews with suspected perpetrators are best conducted by specifically trained professionals.
The authors note that successful treatment usually doesn’t involve just a single intervention of removing the victim from an abusive environment. Instead, successful interventions are typically “interprofessional, ongoing, community-based, and resource-intensive.” They write that the role for physicians is not to lead interventions, but rather to identify abuse, know the local organizations and services that provide resources to victims and refer patients to them, while coordinating care. These services can include Adult Protective Services, police and district attorneys, home health care organizations and appropriate nonprofits, and more.
Elder Abuse in the Time of COVID-19—Increased Risks for Older Adults and Their Caregivers Lena K. Makaroun, Rachel L. Bacrach and Ann-Marie Rosland. The American Journal of Geriatric Psychiatry , May 2020
The stay-at-home orders and recommendations intended to protect people, especially older people, from COVID-19 have created additional risks for elder abuse, note the authors of this perspective article. “Even in the best of times, elder abuse cases are rarely detected, with only 1 in 24 cases identified and reported to the appropriate authorities,” the authors write, citing a 2011 report of elder abuse in New York .
In the pandemic environment, older people and their family caregivers may be especially vulnerable to isolation, anxiety, financial stress and difficulty accessing healthcare and supplies, along with increased co-dependency brought on by the changing living conditions. These stressors increase risk factors for elder abuse.
Health care providers and outside caregivers are now less likely to have in-person contact with their patients, relying instead on technology-based communication; however, many older adults are not adept at technology, may not have the necessary hardware devices, and may not be able to speak privately if living with an abuser. And some elder care must be provided in person. The reduction or loss of this care could lead to neglect.
Existing abusive relationships may become more severe or lethal as mood disorders and substance abuse increase among caregivers. Additionally, during the pandemic, “there was a substantial increase in the purchase of firearms and ammunition.”
The pandemic does offer opportunities for positive change, the authors note. Providers who can contact elder patients via technology can now observe patients in their homes and can provide support for caregivers whom they may not typically see during in-person visits. Institutions and organizations are mobilizing programs and support for elders during the pandemic, including the Veterans Health Administration and local agencies on aging. The authors report that “the new challenges presented by the COVID-19 pandemic present an important opportunity to forge these new partnerships.”
The pandemic also presents opportunities for new research. The authors write, “Perhaps most understudied, and the area where new revelations could have the biggest impact, are caregiver-related risk factors. With many people experiencing caregiving stress and concern about whether loved ones’ needs will be met, caregivers may be more open to participating in research to share their experiences, even uncomfortable ones.”
Elder abuse prevalence in community settings: a systematic review and meta-analysis Yongjie Yon, et al. The Lancet Global Health , February 2017
This meta-analysis of 52 international studies in 28 countries describes how prevention of elder abuse requires a better understanding of the breadth of the problem. The authors report that “elder abuse seems to affect 1 in 6 older adults worldwide, which is roughly 141 million people.” Psychological abuse was reported most often, at a 11.6% pooled prevalence estimate (pooled prevalence is a statistical technique for pooling results of many epidemiological studies), followed by financial abuse, neglect, physical abuse and sexual abuse.
The authors note that reported rates vary widely. “For example, national estimates of past-year abuse prevalence rate ranged between 2.6% in the UK and 4% in Canada to 18.4% in Israel and 29.3% in Spain,” they write. That’s due in part to a lack of consensus on how to define and measure different types of elder abuse, they note, making elder abuse a “neglected global health priority.”
The authors report that if the proportion of elder abuse cases remain constant through the aging global population, they expect elder abuse victims to number 330 million by 2050.
The National Elder Mistreatment Study: An 8-year longitudinal study of outcomes Ron Acierno, et al. Journal of Elder Abuse & Neglect , 2017
This study is the 8-year follow-up to a 2011 study published in the American Journal of Public Health , “ Prevalence and Correlates of Emotional, Physical, Sexual, and Financial Abuse and Potential Neglect in the United States: The National Elder Mistreatment Study. ” The original study analyzed interviews (in English and Spanish) with over 5,500 respondents across the continental U.S., finding that 1 in 10 self-reported some type of elder abuse or neglect. The follow-up study attempted to contact all 752 original participants who reported mistreatment since age 60, of which they reached 183. They also interviewed 591 randomly selected non-mistreated participants from the original study.
The authors of the 2017 paper found that lack of social support increased the likelihood of all forms of abuse, while the presence of social support mitigated negative effects of abuse, particularly anxiety and poor health. Few instances of abuse were reported to authorities.
The authors describe how the 2017 follow-up study “represents the first longitudinal epidemiological study of elder mistreatment to date,” and focuses on how abuse affected victims’ health over time.
In the 2017 study, the authors look at the factors that exacerbated or mitigated the long-term effects of elder abuse. Variables of gender, income, and employment status were not as relevant as levels of social support. Further, beyond the effects on elder mistreatment, the researchers report that “low social support consistently predicted negative outcomes” in mental and physical health, even more consistently than did abuse.
“This is encouraging insofar as these findings speak directly to an actionable intervention to prevent both elder mistreatment and its negative effects,” they write.
They recommend that when family and friends can’t provide sufficient levels of social support, policies should further social support programs “in the form of education, volunteerism, or socialization” with examples including online and in-person classes, and social activities and meal programs through senior centers.
Limitations of both studies were that data was self-reported, respondents were all “community-residing” elders (not living in elder care facilities) who were “cognitively intact,” and the stigma of abuse and mental illness may have led to under-reporting. In the follow-up study a significant proportion of the original respondents were “not available for follow-up, either due to death, relocation, or inability to participate.”
Prevalence of elder abuse in institutional settings: systematic review and meta-analysis Yongjie Yon, et al. The European Journal of Public Health , June 2018
This systematic review and meta-analysis, described by the authors as the “first rigorous quantitative synthesis of prevalence estimates for elder abuse in the institutions” estimates a high global prevalence of elder abuse for those living in elder care facilities during the 12 month period preceding this study.
Based on nine international studies that focused on staff-to-resident abuse in six countries, the authors report more than half of the staff interviewed for these studies admitted to elder abuse, with psychological abuse being most common, followed by physical abuse.
Among self-reporting victims, more than a third had experienced psychological abuse. Next-most common was physical abuse, followed by financial abuse, neglect and sexual abuse. While abuse in elder care facilities also occurs resident-to-resident and visitor-to-resident, the selected papers did not include these categories of data.
The main risk factors in an institutional setting are reported as “being female, presence of a cognitive impairment and disability, and being older than 74 years old,” with a “strong association between increasing dependency and elder abuse occurring” regardless of whether older adults live in an elder care facility or elsewhere.
Staff who self-reported committing abuse described stress from staff shortages and time pressure. The authors also cite staffing data from prior research in which staff who committed abuse described emotional exhaustion. In addition, higher ratios of patients to registered nurses correlated to higher levels of abuse, while “increased presence of qualified nurses” correlated with lower risk.
Comparing older adult and child protection policy in the United States of America Peiyi Lu and Mack Shelley. Ageing & Society , September 2019
This study compares child and adult protection policies in the U.S., noting that by 2050 the U.S. is “expected to have 88.5 million older adults and 79.9 million children.” The authors describe an estimated prevalence of abuse as more than five times higher among older adults than children (10% vs 1.71%); however, they note that the data for elder abuse is not always available or comparable to the detailed data on child abuse.
Overall, U.S. adult protection policies were developed later and more slowly than those for children. The authors include comparisons across multiple factors including response services, post-response services, prevention services and allocation of resources and funding. “Compared to child protection policy, older adult protection policy lacked federal legislative and administrative direction, well-developed diagnosis and evaluation tools, a national data system, sufficient federal funds and a comprehensive response mechanism,” they write.
The autonomy of adults complicates some elements of adult protection. While children are viewed as a vulnerable population requiring protection, “older adults have lived independently for most of their lives and still expect to be independent in most periods of their late life. When abuse happens, especially for the self-neglect and financial exploitation cases, it is difficult to determine whether it is intentional.”
As one example, federal protection policies mandate reporting for both child and adult abuse. Child protection policies are more strictly implemented than those for adults.
“There is a trade-off,” the authors write, “between protecting older adults’ rights to be free from violence and exploitation, and maintaining their individual autonomy.” They cite other researchers who believe that a mandatory system not only interferes with the autonomy of older adults but presents ethical conflicts for physicians.
Financial Exploitation of Older Adults: A Population-Based Prevalence Study Janey C. Peterson, et al. Journal of General Internal Medicine , July 2014
The authors conducted over 4,000 interviews in 2008–2009 with older adults in New York state not living in elder care facilities to identify those who had experienced financial exploitation, defined as: “improper use of funds, property or resources, coerced property transfers, denial of access to assets, fraud, false pretense, embezzlement, conspiracy, or falsifying records.” They found that almost 1 in 20 adults were victims of financial exploitation in their older years.
Older adults who self-reported financial abuse were more likely to already be economically, medically or otherwise demographically vulnerable. Poverty was an indicator for financial exploitation, possibly because individuals in poverty may be sharing homes with others. Family members are most often (57.9 % of the time) the ones financially exploiting victims, with adult children being the primary perpetrators. In addition, living with non-spousal family members put older adults at greater risk. Other perpetrators, in order of occurrence, were friends and neighbors, and home care aides.
Being Black was associated with greater relative risk of being a victim of financial abuse. People who have trouble with the tasks of daily living (e.g. managing finances, shopping, cooking and cleaning, or taking medications) were also at higher risk, as people providing assistance have access to their finances. Other factors associated with financial exploitation were “non-use of social services, need for [assisted daily living] assistance, poor self-rated health, no spouse/partner and lower age.”
The authors conclude, “In addition to robbing older adults of resources, dignity, and quality of life, victims of [financial abuse] likely cost our society dearly in the form of increased entitlement encumbrances, health care, and other costs.”
As with other studies of elder abuse, the limitations are that data was self-reported, did not include participants with dementia, and that elder people are often less likely to report abuse, leading to underreporting.
Risk Factors for Elder abuse and Neglect: A Review of the Literature Jennifer E. Story. Aggression and Violent Behavior , Jan-Feb 2020
To help health care providers identify older adults at risk for abuse, this literature review provides a summary of risk factors that increase the likelihood of becoming either an abuse victim or perpetrator. Many risk factor categories are similar for perpetrators and victims. For example, “dependency” is a risk for a perpetrator, particularly if they are financially dependent on the victim, possibly leading to anger and abuse. For victims, dependency creates a vulnerability because it increases isolation and makes it harder to seek help.
The paper includes a detailed chart with the categories of factors that can increase the likelihood of becoming either a victim or a perpetrator of elder abuse: physical and mental health problems; substance abuse; dependency; problems with stress, coping and attitudes; problems with relationships, and previous experience with or witness to abuse.
Screening for elder mistreatment in emergency departments: current progress and recommendations for next steps Tony Rosen, Timothy F. Platts-Mills & Terry Fulmer. Journal of Elder Abuse & Neglect , June 2020
This paper advocates for universal screening for elder abuse in emergency departments. The authors describe the “dismally low rate at which emergency providers are currently recognizing or reporting abuse” even though, compared with other older adults, victims of elder abuse seek emergency care more frequently and primary care less frequently. They note that “annual rates of ED usage by elder abuse victims are 3 times greater than non-victims.”
Current screening tools, the authors argue, are either likely to miss incidents of elder abuse or are too long and complex for the busy, chaotic emergency department environment. Patients are often screened in the emergency department for safety issues such as domestic abuse with a single vague question: “Do you feel safe at home?”
Instead, the authors propose a two-step screening process: a brief universal screen followed by a comprehensive screen for those positively identified. The initial screen would be designed to more specifically detect elder abuse, with questions such as: “Has anyone close to you harmed you?” or “Has anyone close to you failed to give you the care that you need?” Another option for the initial screen would be to design the electronic health record system to identify at-risk patients. The second-step comprehensive screening would involve a brief cognitive assessment, questions for the patient and a physical exam.
To improve emergency department detection and intervention for elder abuse they also recommend stronger ties between emergency departments and Adult Protection Services, development of multi-disciplinary response teams modeled after similar teams for child protection, and involving emergency medical service providers in initial screenings.
A note on guardianship abuse
There’s a relative dearth of peer-reviewed research on a specific type of abuse called guardianship abuse. This occurs when a court-appointed guardian, who is typically granted control over an elder person’s financial and medical decisions, takes advantage of their position in an abusive way. As described in Rachel Aviv’s 2017 New Yorker article “ How the Elderly Lose Their Rights,” abusive guardians overtly exploit the system to steal from those they’ve been entrusted to protect. Some guardians forge relationships with hospital personnel to help them identify potential vulnerable clients and then convince courts of the need for guardianship, even when family members object. These abusive guardians have convinced physicians to prescribe sedating medications and oftentimes isolate their clients from family or friends.
The scope of the problem and devising remedies has been hindered by lack of data. Testifying before the United States Senate Special Committee on Aging in April, 2018, Dr. Pamela Teaster, professor and director of the Center for Gerontology at Virginia Tech, said that “despite estimates that some 1.5 million adults are under guardianship, in 2018, not one single state in the country can identify its people under guardianship.”
No central national database exists to identify guardians and track potential abuse. Oversight of guardians varies by state. For example, only some states require background checks and few have safeguards to protect against abuse of the system.
In 2018 the U.S. Senate’s Special Senate Committee on Aging published a report on guardianship abuse, Ensuring Trust: Strengthening State Efforts to Overhaul the Guardianship Process and Protect Older Americans . While special committees have no legislative authority, they can study issues and make legislative recommendations. Committee Chairman Sen. Susan Collins and Ranking Member Sen. Bob Casey subsequently sponsored the “ Guardianship Accountability Act of 2019 ,” which, in its most recent action, was sent to the Committee on the Judiciary in February 2019. The bill addresses many of the 2018 report’s recommendations, including the establishment of a National Online Resource Center on Guardianship.
Guardianship may not always be the best way to assist an older adult who needs assistance. As described in the 2018 Senate Ensuring Trust report , “a full guardianship order may remove more rights than necessary and may not be the best means of providing support and protection to an individual.” One relatively new alternative to guardianship is called “supported decision-making. This concept, which first gained traction in the disability rights community, is now proposed as an option to guardianship for some older adults, including those with dementia, and is supported by the American Bar Association. Under supported decision-making the individual relies on support from family, friends, and/or service organizations to help make their own decisions, without having to relinquish legal autonomy. These arrangements can range from informal understandings to written agreements, which are recognized as legally enforceable in nine states.
In a recent issue of Generations , Erica F. Wood, who is the assistant director of the American Bar Association Commission on Law and Aging, provides information for those working with older populations on how to avoid guardianship or how to ensure a proper guardianship. She provides a practical information on how to manage a legal process that will potentially result in the appointment of a guardian.
She suggests obtaining legal representation, and describes possible actions to take before a hearing, including checking applicable laws, assessing for less-restrictive measures than guardianship, and collecting evidence. If the court does appoint a guardian the author describes which aspects of the guardianship to investigate (e.g. who’s the guardian; how will assets be protected), and how to monitor the guardian (e.g. reviewing reports and accounts) and to legally protect the adult under guardianship, by reporting abuse or exploitation or seeking a restoration of rights.
Wood also identifies six common scenarios that can lead to legal guardianship, including a medical crisis, a family feud, discharge from hospital to an elder facility, abuse, eviction and an unpaid care bill.
Frequently Asked Questions by Guardians about the COVID-19 Pandemic
This COVID-19 resource document for professional and family guardians was jointly created by the American Bar Association, the National Center for State Courts and the National Guardianship Association (a professional association). It includes information on accessing and communicating with older adults living in facilities during the pandemic and protecting the legal, medical and financial rights of older adults under guardianship.
Restoration of Rights in Adult Guardianship: Research & Recommendations American Bar Association Commission on Law and Aging with the Virginia Tech Center for Gerontology, 2017
This report describes that an “unknown number” of adults remain under guardianship longer than necessary or could have benefitted from less-restrictive support from the outset. The report focuses on guardianship for all ages, and includes legal research on restoration of rights by state, as well as court file research to extract data on guardianship.
Guardianship and Supported Decision Making
Among the resources on this American Bar Association page are yearly (2013–2019) summaries of state laws and policies regarding guardianship.
National Center for State Courts: Center for Elders
The National Center for State Courts is an independent, nonprofit “court improvement” organization that provides research, information services, education, and consulting to professionals involved in the workings of state courts. Its Center for Elders includes information on issues likely to concern state courts regarding aging, elder abuse and guardianship.
National Center on Elder Abuse
The National Center on Elder Abuse is a program of the U.S. Administration on Aging , which includes research, statistics and data, risk factors, and the multiple definitions of “How Is Elder Abuse Defined for Research Purposes,” among other resources. They’ve recently added a page on COVID-19 with resources for identifying and reporting abuse during the pandemic.
The Center also published a 2018 guide, “Understanding and Working with Adult Protective Services.”
National Center on Law & Elder Rights
As part of the U.S. Department of Health & Human Services, NCLER has tools and resources for legal assistance regarding elder rights, particularly for those with the “greatest economic and social needs.”
The U.S. Department of Justice Elder Justice Initiative
This site has extensive resources regarding all types categories of elder abuse, focused on the justice system, with information for victim specialists, law enforcement and prosecutors, as well as specific rural and Tribal resources.
Centers for Disease Control and Prevention
The CDC published the report Elder Abuse Surveillance in 2016 , which provides “uniform definitions and recommended core data elements for possible use in standardizing the collection of [elder abuse] data locally and nationally.”
United State Government Accountability Office Elder Abuse , Report to Congressional Requesters, 2016
Focusing on the issue of guardianship for older adults, the report is based on research with federal agencies, relevant state court officials, and nongovernmental organizations with expertise in guardianship-related issues.
Academic Centers that Focus on Elder Abuse
Center of Excellence on Elder Abuse & Neglect, University of California, Irvine, School of Medicine
This center’s website has extensive information across multiple disciplines, including links to national resources and tools for promising practices , along with their own research publications .
Center for Gerontology at Virginia Tech
The center’s Resource page includes resources for preventing abuse, as well as specific information on intimate partner violence and violence against rural older women.
USC Center on Elder Mistreatment
The University of Southern California’s Center on Elder Mistreatment is a multi-disciplinary academic research center specializing on issues of elder mistreatment and includes publications on their research topics. One of their key projects is on the use of multi-disciplinary teams for elder abuse interventions.
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