Elderly abuse

**Elder abuse** (also called "elder mistreatment," "senior abuse," "abuse in later life," "abuse of older adults," "abuse of older women," and "abuse of older men") is "a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person."[1] This definition has been adopted by the World Health Organization (WHO) from a definition put forward by Action on Elder Abuse in the UK. Laws protecting the elderly from abuse are similar to, and related to, laws protecting dependent adults from abuse.

The core element to the harm of elder abuse is the "expectation of trust" of the older person toward their abuser. Thus, it includes harms by people the older person knows, or have a relationship with, such as a spouse, partner or family member, a friend or neighbor, or people that the older person relies on for services. Many forms of elder abuse are recognized as types of domestic violence or family violence, since they are committed by family members. Paid caregivers have also been known to prey on their elderly patients.

While there are a variety of circumstances considered as elder abuse, it does not include general criminal activity against older persons, such as home break-ins, "muggings" in the street or "distraction burglary", where a stranger distracts an older person at the doorstep, while another person enters the property to steal.

The abuse of elders by caregivers is a worldwide issue. In 2002, WHO brought international attention to the issue of elder abuse.[2] Over the years, government agencies and community professional groups, worldwide, have specified elder abuse as a social problem.[3] In 2006 the International Network for Prevention of Elder Abuse (INPEA) designated June 15 as World Elder Abuse Awareness Day (WEAAD) and an increasing number of events are held across the globe on this day to raise awareness of elder abuse, and highlight ways to challenge such abuse.[4]

## Types

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

There are several types of abuse of older people that are generally recognized as being elder abuse, including:[5][6]

* **Physical**: e.g. hitting, punching, slapping, burning, pushing, kicking, restraining, false imprisonment / confinement, or giving excessive or improper medication as well as withholding treatment and medication.
* **Psychological/Emotional**: e.g. humiliating a person. A common theme is a perpetrator who identifies something that matters to an older person and then uses it to coerce an older person into a particular action. It may take verbal forms such as yelling, name-calling, ridiculing, constantly criticizing, accusations, blaming, or non verbal forms such as ignoring, silence, shunning or withdrawing affection.
* **Elder financial abuse**: also known as financial exploitation, involving misappropriation of financial resources by family members, caregivers, or strangers, or the use of financial means to control the person or facilitate other types of abuse.
* **Sexual**: e.g. forcing a person to take part in any sexual activity without his or her consent, including forcing them to participate in conversations of a sexual nature against their will; may also include situations where person is no longer able to give consent (dementia)
* **Neglect**: e.g. depriving a person of proper medical treatment, food, heat, clothing or comfort or essential medication and depriving a person of needed services to force certain kinds of actions, financial and otherwise. Neglect can include leaving an at-risk (i.e. fall risk) elder person unattended. The deprivation may be intentional (active neglect) or happen out of lack of knowledge or resources (passive neglect).

In addition, some U.S. state laws[7] also recognize the following as elder abuse:

* **Abandonment**: deserting a dependent person with the intent to abandon them or leave them unattended at a place for such a time period as may be likely to endanger their health or welfare.[8] Elder abuse includes deserting an elderly, dependent person with the intent to abandon them or leave them unattended at a place for such a time period as may be likely to endanger their health or welfare.[8]
* **Rights abuse**: denying the civil and constitutional rights of a person who is old, but not declared by court to be mentally incapacitated. This is an aspect of elder abuse that is increasingly being recognized and adopted by nations
* **Self-neglect**: any persons neglecting themselves by not caring about their own health, well-being or safety. Self-neglect (harm by self) is treated as conceptually different than abuse (harm by others). Elder self-neglect can lead to illness, injury, or even death. Common needs that older adults may deny themselves, or ignore are the following: Sustenance (food or water); cleanliness (bathing and personal hygiene); adequate clothing for climate protection; proper shelter; adequate safety; clean and healthy surroundings; medical attention for serious illness; essential medications.[9] Self-neglect is often created by an individual's declining mental awareness or capability. Some older adults may choose to deny themselves some health or safety benefits, which may not be self-neglect. This may simply be their personal choice. Caregivers and other responsible individuals must honor these choices if the older adult is sound of mind. In other instances, the older adult may lack the needed resources, as a result of poverty, or other social condition. This is also not considered as "self neglect".[10]
* **Institutional abuse** refers to physical or psychological harms, as well as rights violations in settings where care and assistance is provided to dependant older adults or others.

## Warning signs

The key to prevention and intervention of elder abuse is the ability to recognize the warning signs of its occurrence. Signs of elder abuse differ depending on the type of abuse the victim is suffering. Each type of abuse has distinct signs associated with it.

* **Physical abuse** can be detected by visible signs on the body, including bruises, scars, sprains, or broken bones. More subtle indications of physical abuse include signs of restraint, such as rope marks on the wrist, or broken eyeglasses.[11]
* **Emotional abuse** often accompanies the other types of abuse and can usually be detected by changes in the personality or behavior. The elder may also exhibit behavior mimicking dementia, such as rocking or mumbling.[11]
* **Financial exploitation** is a more subtle form of abuse, in comparison to other types, and may be more challenging to notice. Signs of financial exploitation include significant withdrawals from accounts, belongings or money missing from the home, unpaid bills, and unnecessary goods or services.[11]
* **Sexual abuse,** like physical abuse, can be detected by visible signs on the body, especially around the breasts or genital area. Other signs include inexplicable infections, bleeding, and torn underclothing.[11]
* **Neglect** is a type of abuse in that it can be inflicted either by the caregiver or oneself. Signs of neglect include malnutrition and dehydration, poor hygiene, noncompliance to a prescription medication, and unsafe living conditions.[11]

In addition to observing signs in the elderly individual, abuse can also be detected by monitoring changes in the caregiver's behavior. For example, the caregiver may not allow them to speak to or receive visitors, exhibit indifference or a lack of affection towards the elder, or refer to the elder as "a burden." Caregivers who have a history of substance abuse or mental illness are more likely to commit elder abuse than other individuals.[12]

Abuse can sometimes be subtle, and therefore difficult, to detect. Regardless, awareness organizations and research advise to take any suspicion seriously and to address concerns adequately and immediately.

## Health consequences

The health consequences of elder abuse are serious. Elder abuse can destroy an elderly person's quality of life in the forms of:[13]

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

The risk of death for elder abuse victims are three times higher than for non-victims.[14]

## Common abusers

An abuser can be a spouse, partner, relative, a friend or neighbor, a volunteer worker, a paid worker, practitioner, solicitor, or any other individual with the intent to deprive a vulnerable person of their resources. Relatives include adult children and their spouses or partners, their offspring and other extended family members. Children and living relatives who have a history of substance abuse or have had other life troubles are of particular concern. For example, HFE abusive individuals are more likely to be a relative, chronically unemployed, and dependent on the elderly person.[15]

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

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

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

Within paid care environments, abuse can occur for a variety of reasons. Some abuse is the willful act of cruelty inflicted by a single individual upon an older person. In fact, a case study in Canada suggests that the high elder abuse statistics are from repeat offenders who, like in other forms of abuse, practice elder abuse for the Schadenfreude associated with the act. More commonly, institutional abuses or neglect may reflect lack of knowledge, lack of training, lack of support, or insufficient resourcing. Institutional abuse may be the consequence of common practices or processes that are part of the running of a care institution or service. Sometimes this type of abuse is referred to as "poor practice," although this term reflects the motive of the perpetrator (the causation) rather than the impact upon the older person.

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

## Risk factors

There are several risk factors, which increase the likelihood that an elderly person will become a victim of elder abuse. Such risk factors for elder abuse include an elderly person who:[16]

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

There are also several risk factors, which increase the likelihood that a caregiver will participate in elder abuse. Such risk factors for elder abuse include a caregiver who:[16]

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

## Research and statistics

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

One study suggests that around 25% of vulnerable older adults will report abuse in the previous month, totaling up to 6% of the general elderly population.[17] However, some consistent themes are beginning to emerge from interaction with abused elders, and through limited and small scale research projects. Work undertaken in Canada suggests that approximately 70% of elder abuse is perpetrated against women and this is supported by evidence from the AEA helpline in the UK, which identifies women as victims in 67% of calls. Also domestic violence in later life may be a continuation of long term partner abuse and in some cases, abuse may begin with retirement or the onset of a health condition.[18] Certainly, abuse increases with age, with 78% of victims being over 70 years of age.[19]

The higher proportion of spousal homicides supports the suggestion that abuse of older women is often a continuation of long term spousal abuse against women. In contrast, the risk of homicide for older men was far greater outside the family than within.[20] This is an important point because the domestic violence of older people is often not recognized and consequently strategies, which have proved effective within the domestic violence arena, have not been routinely transferred into circumstances involving the family abuse of older people.

According to the AEA helpline in the UK, abuse occurs primarily in the family home (64%), followed by residential care (23%), and then hospitals (5%), although a helpline does not necessarily provide a true reflection of such situations as it is based upon the physical and mental ability of people to utilize such a resource.[19]

Research conducted in New Zealand broadly supports the above findings, with some variations. Of 1288 cases in 2002–2004, 1201 individuals, 42 couples, and 45 groups were found to have been abused. Of these, 70 percent were female. Psychological abuse (59%), followed by material/financial (42%), and physical abuse (12%) were the most frequently identified types of abuse. Sexual abuse occurred in 2% of reported cases.[21] Age Concern New Zealand found that most abusers are family members (70%), most commonly sons or daughters (40%). Older abusers (those over 65 years) are more likely to be husbands.[21]

In 2007, 4,766 cases of suspected abuse, neglect, or financial exploitation involving older adults were reported, an increase of 9 percent over 2006. 19 incidents were related to a death, and a total of 303 incidents were considered life-threatening. About one in 11 incidents involved a life-threatening or fatal situation.[22]

In 2012, the study called Pure Financial Exploitation vs. Hybrid Exploitation Co-Occurring With Physical Abuse and/or Neglect of Elderly Persons�by Shelly L. Jackson and Thomas L. Hafemeister brought attention to the hybrid abuse that elderly persons can experience. This study revealed that victims of hybrid financial exploitation or HFE lost an average of $185,574, a range of $20–$750,000.[15]

### Barriers to obtaining statistics

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

* Elder abuse is largely a hidden problem and tends to be committed in the privacy of the elderly person's home, mostly by his or her family members[23]
* Elder abuse victims are often unwilling to report their abuse for fear of others' disbelief, fear of loss of independence, fear of being institutionalized, fear of losing their only social support (especially if the perpetrator is a relative), and fear of being subject to future retaliation by the perpetrator(s),[24][25][26][27]
* Elder abuse victims' cognitive decline and ill health may prevent them from reporting their abuse[28]
* Lack of proper training of service providers, such as social workers, law enforcement, nurses, etc., about elder abuse, therefore the number of cases reported tend to be low[29]
* The subjective nature of elder abuse, which largely depends on one's interpretation.[30]
* Another reason why there is a lack of accurate statistics is the debate of whether to include self-neglect or not. Many are unsure if it should be included since it does not involve another person as an abuser. Those opposed to the inclusion of self-neglect make the claim that it is a different form of abuse and thus, should not be included in the statistics. Due to this discrepancy and the others mentioned above, it is difficult to get accurate data concerning the abuse of the elderly.[31]

## Prevention

Doctors, nurses, and other medical personnel can play a vital role in assisting elder abuse victims. Studies have shown that elderly individuals, on average, make 13.9 visits per year to a physician.[32] Although there has been an increase in awareness of elder abuse over the years, physicians tend to only report 2% of elder abuse cases.[13] Reasons for lack of reporting by physicians include a lack of current knowledge concerning state laws on elder abuse, concern about angering the abuser and ruining the relationship with the elderly patient, possible court appearances, lack of cooperation from elderly patients or families, and lack of time and reimbursement.[13] Through education and training on elder abuse, health care professionals can better assist elder abuse victims.

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

In addition, community involvement in responding to elder abuse can contribute to elderly persons' safety. Communities can develop programs that are structured around meeting the needs of elderly persons. For example, several communities throughout the United States have created Financial Abuse Specialist Teams,[33] which are multi-disciplinary groups that consist of public and private professionals who volunteer their time to advise Adult Protective Services (APS), law enforcement, and private attorneys on matters of vulnerable adult financial abuse.[34]