Elder abuse

Editor(s)-in-Chief: C. Michael Gibson, M.S.,M.D. [mailto:mgibson@perfuse.org] Phone:617-632-7753; Angela Botts, M.D., Beth Israel Deaconess Medical Center Geriatric Medicine [mailto:abotts@bidmc.harvard.edu]

Overview
Elder abuse is often defined 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." This definition was established by Action on Elder Abuse in the UK, but was then subsequently adopted by the World Health Organisation. Core features of this definition are that such abuse is defined by the 'expectation of trust' of the older person toward their abuser. Consequently, it excludes more general criminal activity such as 'muggings' in the street or 'distraction burglary', where one stranger distracts an older person at their doorstep while another enters the property to steal.

In 2006 the [International Network for Prevention of Elder Abuse (INPEA)] designated June 15th 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. 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 universally recognised as being elder abuse and these include:


 * Physical: e.g. hitting, punching, slapping, burning, pushing, kicking, restraining, false imprisonment/confinement, or giving too much medication or the wrong medication;


 * Psychological: e.g. shouting, swearing, frightening, blaming, ridiculing, constantly criticizing, ignoring or humiliating a person. A common theme is a perpetrator who identifies something that matters to an older person and then uses it to coerce an older person into a particular action;


 * Financial: e.g. illegal or unauthorized use of a person’s property, money, pension book or other valuables (including changing the person's will to name the abuser as heir), often fraudulently obtaining power of attorney, followed by deprivation of money or other property, or by eviction from own home;


 * 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;


 * Neglect: e.g. depriving a person of food, heat, clothing or comfort or essential medication.

In addition some countries also recognise the following as elder abuse:


 * Rights abuse: denying the civil and constitutional rights of a person who is old, but not declared by court to be mentally incapacitated. This is an aspect of elder abuse that is increasingly being recognised and adopted by nations


 * Self-neglect: elderly persons neglecting themselves by not caring about their own health or safety.

Institutional abuse and racial abuse are not usually included in such categories as they tend to denote the motivation or circumstances, rather than the manifestation of abuse. That is not to suggest that institutional practices, often marginalised as examples of 'poor practice', do not form a major aspect of elder abuse, or that racially motivated abuse is not a signicant area of concern.

Common abusers of older people
Perpetrators of elder abuse, can include anyone in a position of control or authority, or anyone who 'grooms' an older person in order to establish a relationship of trust. An abuser can be a partner, a relative, a friend or neighbour, a volunteer worker, a paid worker or a practitioner (e.g. a social worker, bank worker or solicitor). The circumstances giving rise to abuse can include situations where the victim is physically or financially dependent on the abusive caregiver, sometimes described as dependent adult abuse. Abusing relatives represent the majority of abusers, and tend to be the spouse/partner or sons and daughters, although the type of abuse differs according to the relationship. In some situations such abuse is 'domestic violence grown old', a situation in which the abusive behaviour of one partner toward another continues into old age. In some cases the older abuser becomes the older victim and the younger victim becomes the younger abuser. In other situations it is older people attempting to care and support other older people 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 institutional in that it is a consequence of practices or processes that are integral to the running of a care institution or service. Some abuse is the wilful act of cruelty inflicted by a single individual upon an older person. And some abuse is a consequence of lack of knowledge, lack of training, lack of support, or insufficient resourcing. Sometimes this type of abuse is referred to as 'poor practice', although it is important to recognise that this term reflects the motive of the perpetrator (the causation) rather than the impact upon the older person.

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

Abuse statistics
There has been limited research into the nature and extent of elder abuse, and it is often argued that the absence of such data is a reflection of the low priority given to work associated with older people. One study suggests that around 25% of vulnerable older adults will report abuse in the previous month, totalling up to 6% of the general elderly population. 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. Certainly, abuse increases with age, with 78% of victims being over 70 years of age.

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. This is an important point because the domestic violence of older people is often not recognised, 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 utilise such a resource.

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

Self abuse and neglect
Elders can abuse / neglect themselves by not caring about their own personal health and well-being. Elder self-neglect can lead to illness, injury or even death. Common needs that the senior 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

Elders 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 senior is sound of mind.

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

Age Concern Newfoundland 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.