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Elder Abuse - Synthesis

Introduction

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.


Quality Statement

The included systematic reviews [1-4,8-11] scoping review [12] and literature reviews [13,14] are of variable quality (low, moderate and high) 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. Other papers were included to give context to this topic. [6,7,15-17]

None of the included research relates to of elder abuse in a palliative care or end-of-life context.
 

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.” Mysyuk et al. [13] 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. The World Health Organization (WHO) World report on health and ageing [17] 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.

A detailed evidence-based description of elder abuse in Australia does not exist and currently. 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).

Resident-to-resident abuse or resident-to-resident aggression (RRA) was the focus of a systematic review [9] and a scoping review. [12] 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.

Studies by Yan et al. [11] describe 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 by Sooryanarayana et al. [14] and Dong et al. [4] These considerations may 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. [15,16]

Interventions to monitor, prevent and educate

There is a great paucity of evidence-based prevention and intervention strategies to assist the victims of elder abuse. [4] Six systematic reviews [1-3, 5, 8, 10] 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. [8] 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. [5] 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 [10] 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. [10] 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. [10] 
 

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.


Page updated 09 January 2018

  • References

  1. Ayalon L, Lev S, Green O, Nevo U. A systematic review and meta-analysis of interventions designed to prevent or stop elder maltreatment. Age Ageing. 2016 Mar;45(2):216-27.
  2. Baker PR, Francis DP, Hairi NN, Othman S, Choo WY. Interventions for preventing abuse in the elderly. Cochrane Database Syst Rev. 2016 Aug 16;(8):CD010321.
  3. Du Mont J, Macdonald S, Kosa D, Elliot S, Spencer C, Yaffe M. Development of a comprehensive hospital-based elder abuse intervention: an initial systematic scoping review. PLoS One. 2015 May 4;10(5):e0125105.
  4. Dong X, Chen R, Chang ES, Simon M. Elder abuse and psychological well-being: a systematic review and implications for research and policy--a mini review. Gerontology. 2013;59(2):132-42.
  5. Day A, Boni N, Evert H, Knight T. An assessment of interventions that target risk factors for elder abuse. Health Soc Care Community. 2016 Feb 22.
  6. Kaspiew R, Carson R, Rhoades H. Elder abuse: Understanding issues, frameworks and responses [Internet]. 2016 Feb [cited 2017 May 22].
  7. Aged & Community Services Australia (ACSA). Elder Abuse: ACSA Position Statement (718kb pdf). ASCA; 2016 Nov.
  8. Alt KL, Nguyen AL, Meurer LN. The Effectiveness of Educational Programs to Improve Recognition and Reporting of Elder Abuse and Neglect: A Systematic Review of the Literature. J Elder Abuse Negl. 2011 Jul;23(3):213-33.
  9. Ferrah N, Murphy BJ, Ibrahim JE, Bugeja LC, Winbolt M, LoGiudice D, et al. Resident-to-resident physical aggression leading to injury in nursing homes: a systematic review. Age Ageing. 2015 May 1;44(3):356-64.
  10. Touza Garma C. Influence of health personnel's attitudes and knowledge in the detection and reporting of elder abuse: An exploratory systematic review. Psychosocial Intervention. 2017 Aug;26(2):73-91.
  11. Yan E, Chan KL, Tiwari A. A systematic review of prevalence and risk factors for elder abuse in Asia. Trauma Violence Abuse. 2015 Apr;16(2):199-219. doi: 10.1177/1524838014555033. Epub 2014 Nov 6.
  12. McDonald L, Sheppard C, Hitzig SL, Spalter T, Mathur A, Mukhi JS. Resident-to-Resident Abuse: A Scoping Review. Can J Aging. 2015 Jun;34(2):215-36.
  13. Mysyuk Y, Westendorp RG, Lindenberg J. Added value of elder abuse definitions: a review. Ageing Res Rev. 2013 Jan;12(1):50-7.
  14. Sooryanarayana R, Choo WY, Hairi NN. A review on the prevalence and measurement of elder abuse in the community. Trauma Violence Abuse. 2013 Oct;14(4):316-25.
  15. Department of Social Services. National Ageing and Aged Care Strategy for People from Culturally and Linguistically Diverse (CALD) Backgrounds. Canberra: Commonwealth of Australia (Department of Social Services); 2015.
  16. Mavromaras K, Knight G, Isherwood L, Crettenden A, Flavel J, Karmel T, et al. 2016 National Aged Care Workforce Census and Survey – The Aged Care Workforce, 2016. Canberra: Commonwealth of Australia (Department of Health); 2017.
  17. World Health Organisation (WHO). World report on ageing and health (4.5MB pdf). WHO. Geneva, Switzerland: 2015.