Elder Abuse - Synthesis

Elder Abuse - Synthesis


Increasing attention is being directed to elder abuse. Elder abuse is a complex and significant global social, health and human rights issue [1-8] which involves multiple levels of government and different agencies. [5] Service providers and health professionals have moral, ethical and regulatory responsibilities to identify, prevent and redress harm and neglect. [5,9,10]

Quality Statement

The included systematic reviews [1-4,7,8,11-15], a scoping review [16] and literature reviews [17,18] are of variable quality and include research of variable quality and methodology rigour. Many of the studies suffer from a small sample size. Research into elder abuse is growing in quality and quantity but is hampered by a lack of agreement on definitions and measurement, and the hesitancy of people to disclosure information. Only one review relates to elder abuse in a palliative care or end-of-life context and it focuses on dementia. [8]

Other sources were included to give context to this topic. [5,6,9,19-27]

Evidence Synthesis

Definitions and understanding the significance of elder abuse

Commonly cited in the literature is the following definition used by the World Health Organization (WHO) and the International Network for the Prevention of Elder Abuse: “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.” [1,2,5,8-10,18] Mysyuk et al. [17] recommend that this definition be used consistently used in research as a first step in establishing a stable and common definition to strengthen the cohesiveness of research.

The lack of agreement of definition of elder abuse has made it difficult to confidently describe its extent and prevalence. [5,7,8,13,17,18] The World Health Organization (WHO) World report on health and ageing [21] estimates the prevalence of elder abuse across middle- to high-income countries as between 0.2 – 9.2% but these statistics do not include older adults with cognitive impairments and those living in nursing homes or long-term care facilities; these groups may be at particular risk.

Elder abuse is a complex issue. The abuse is often committed by someone with whom the older person has a relationship of trust such as a partner, family member, friend, carer or professional person. [5,25,27] Abuse can occur in several settings, including the older person's home.

The main types of elder abuse include physical abuse (e.g. slapping, pushing, inappropriate use of force or of restraints), emotional or psychological abuse (e.g. yelling, humiliating, threatening, treating like a child), financial or material abuse (e.g. stealing, selling personal belongings without consent, threatening or coercing an older person to hand over an asset, misusing power of attorney), sexual abuse (e.g. non-consensual sexual contact of any kind), and neglect (e.g. failing to provide for basic health or medical needs, abandonment). [1-7,10,12-18,25,27] These five forms of abuse of older people are recognised and defined in the National Plan to Respond to the Abuse of Older Australians (Elder Abuse) 2019-2023 [25] Self-neglect is a well-known geriatric syndrome and is not always regarded as elder abuse. [14]

Resident-to-resident abuse or resident-to-resident aggression (RRA) was the focus of a systematic review [11] and a scoping review. [16] The authors conclude that this under-recognised phenomenon has serious consequences for residents, family members and staff working residential aged care. Dementia, mental health issues and previous aggressive behaviours are recognised as contributing factors.

The review by Yan et al. [13] describes the prevalence of elder abuse in Asia and the cultural considerations of different populations in Asia which shape the prevalence and risk factors. Cultural nuances are also discussed in two other reviews. [8,18] These cultural factors include expectations of duty to care or to be cared for by a family member, and the understanding of what constitutes respect and attention. [8] Cultural sensitivities such as “failure to show respect to an older person”, “lack of a dignified living environment for older parents”, “blaming an elder”, and “insufficient attention paid to or direct expression of disagreement with senior relatives” are identifiable in Asian cultures and can be perceived as abuse. [8] Cultural nuances can be important as approximately one-fifth of older Australians are of culturally and linguistically diverse (CALD) origin and the 22% aged care workforce report being both migrant and speaking a language other than English. [19,20]

Abuse of people living with dementia

Rates of abuse (mistreatment and self-neglect) are higher in older adults with dementia than adults without cognitive impairment. [8] The reported prevalence varies and depends on how people define abuse, and this will include cultural attitudes, expectations, and sensitivities. [8,26] A primary study has demonstrated that for older people with cognitive impairment, using both visual and text prompts helps promote meaningful discussion of their experiences. [26]

Carer burden has been identified as a risk factor for abuse of people living with dementia. [8] In Asian culture, the expectation of taking care of one's parents and a lack of out-of-home care means that family carers are common in the dementia care system. [8] Carers may feel entrapped by their obligations and unprepared and turn their frustration into abusive behaviours. In Western countries, common reasons for assuming a carer role vary. Carers with negative motivations (duty, guilt, social or cultural pressures) are more likely to develop emotional stress and resent their roles, and are at an increased risk of abusing their care recipients. [8]

Prevention is of particular importance for abuse of persons living with dementia as once the abusive cycle has started it can become embedded, and the resulting agitated behaviour does not necessarily reduce with a reduction in abuse. [8]

Interventions to monitor, prevent and educate

There is a paucity of evidence-based prevention and intervention strategies to assist the victims of elder abuse.  Six systematic reviews [1-4,7,12] conclude that there is insufficient trustworthy evidence and that the studies reviewed are generally of low quality, of small scale, poor design and too diverse to enable comparison.

Du Mont et al. [3] reviewed guidelines, frameworks, protocols, manuals, tools, interventions, and tool kits in relation to hospital-based elder abuse interventions. Eighty percent of the interventions were from USA and Canada with only 6% based in Australia. Approximately 80% were developed with input from health and community/social service with only 10% involving the financial sector; the authors saw this as a concern in light of cited studies which shown that financial/material abuse is one of the most common types of elder abuse. A significant finding was the lack of consultation with older people and the general public in the development of interventions.

Ayalon et al. [1] and Baker et al. [2] investigated interventions to prevent or stop elder abuse. [1,2] Baker et al. conclude that it is unclear whether improved knowledge leads to an improvement in skills or behaviour of health professionals and carers. Although educational interventions seem to provoke an increase in reporting of elder abuse it is unclear whether this was due to an increase in willingness to report abuse or whether it reflected an actual increase in the incidence of abuse. The findings by Ayalon et al. [1] indicate that the strongest available evidence was in the education for carers of people with dementia and the alternatives to using restraints.

Alt et al. [7] focussed on education programs to improve recognition and reporting of elder abuse. These authors recommend an in-person and interactive format in education sessions as most beneficial particularly if it provides support in discussions of the potentially disturbing elements of this issue. Health workers often found interaction with local professionals and community members who are dealing with abuse important in developing a realistic understanding of the scope of elder abuse. First-hand accounts and home visits had a profound impact on understanding.

Day et al. [4] assessed interventions that target the risk factors for elder abuse and noted that research in this area is scant and has not grown substantially since a previous review in 2009. Like the previous review, the findings are unable to recommend any intervention or aspects of interventions that are evidence-based and help prevent abuse.

Touza Garma [12] investigated the influence of the knowledge and attitudes of health workers in relation to the detection and reporting of elder abuse. Included studies indicated that health professionals’ actions towards detecting and reporting elder abuse are influenced by the accuracy of their knowledge of abuse, their expectations about the consequences of reporting or their concept of professional role and responsibility. [12] Most studies in this review acknowledged the importance of training to enhance health professionals’ knowledge of abuse detection and rules and procedures of abuser reporting. Although most studies found that training could improve knowledge and attitudes of health professionals, little evidence was found on the effectiveness of such training in increasing the likelihood that cases would be detected and reported. [12]

Evidence Gaps

  • We know little about whether there is elder abuse in a palliative care context.
  • Little is known about the views, experiences actions of palliative care professionals in a palliative care setting with regard to elder abuse in a residential or community setting.
  • It appears that elder abuse can be perceived differently in between cultures and between generations therefore there could be specific issues that arise in an end-of-life context. More research is needed.
  • Neglect, self-neglect, self-harm and refusal of care can be seen as issues in palliative care. More needs to be understood about older people’s capacity to choose and the appropriate elements of the system which supports older Australians.
  • Resident-to-resident abuse or resident-to-resident aggression (RRA) is an emerging and under-recognised phenomenon requiring further attention
  • Abuse of people with dementia is recognised but poorly researched.

Page updated 08 July 2021

  • References

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  9. Aged Care Act 1997 (Cth). 
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