Prevention and intervention
This section outlines a public health model approach to the prevention and intervention of elder abuse in Australia. Specifically, it explores the various legislative, policy and practice frameworks that aim to address elder abuse and summarises the available evidence for particular interventions.
A public health model to the prevention of elder abuse operates at the levels of primary, secondary and tertiary interventions:
- Primary (or universal) interventions target whole communities or populations to prevent elder abuse.
- Secondary interventions target particular at-risk populations (i.e. at-risk adults and/or at-risk perpetrators).
- Tertiary interventions respond to victims and/or perpetrators of elder abuse.
Overall, elder abuse interventions face significant challenges with respect to the complex forms of abuse involved and the lack of a strong evidence base that would inform effective policies and practices (Baker, Francis, Hairi, Othman, & Choo, 2016; Day et al., 2017; Moore & Browne, 2017). In response to these challenges, some have identified the need for prevention and intervention studies to focus on particular sets of risks involving particular victim-perpetrator dyads and specific forms of abuse (Dong, 2015; Jackson & Hafemeister, 2016; Teresi et al., 2016) - for example, older adults with dementia at risk of financial abuse from caregiving relatives.
Primary interventions that aim to prevent elder abuse can be implemented at various levels (e.g. national, state/territory, system, community, organisational, programmatic levels) and target particular populations (e.g. community members, older adults, caregivers, professionals) and sectors (e.g. health, aged care, social, legal or financial sectors) (Day et al., 2017; Joosten et al., 2017; Moore & Browne, 2017). Prevention strategies operating at broader national or state and territory levels may include:
- Commonwealth and state/territory-based legislation relevant to preventing or remediating forms of elder abuse
- Commonwealth and state/territory-based policy frameworks to guide policy and practice
- education and awareness strategies
- sector-wide workforce development and support for relevant professionals.
Funding for elder abuse prevention initiatives may also be considered part of an overall primary intervention strategy (Hirst et al., 2016).
There is currently no over-arching legal framework that addresses elder abuse at a national level in Australia. Instead, a range of intersecting federal and state/territory-based laws cover many of its diverse aspects (Kaspiew et al., 2016). This includes a range of civil and criminal laws across Australian jurisdictions that are not usually specific to elder abuse or older people but may nonetheless apply to particular cases of elder abuse (e.g. physical assault, misuse of powers of attorney, etc.) (ALRC, 2017; Joosten et al., 2017).
The most relevant legal mechanisms in relation to elder abuse at a Commonwealth level are the Aged Care Act 1997 (Cth) and the Age Discrimination Act 2004 (Cth) (Kaspiew et al., 2016; Lacey, 2014). The Aged Care Act primarily contains legal provisions focused on the regulation and monitoring of residential aged-care services, including service accreditation, service provider obligations and the mandatory reporting of physical or sexual assault within federally funded services (Kaspiew et al., 2016).
In its recent inquiry report, the ALRC has recommended the strengthening of the Aged Care Act to: better respond to what it refers to as 'serious incidents'; improve pre-employment screening; and improve regulation around the use of restrictive practices in aged care settings (ALRC, 2017). The Age Discrimination Act has broader legal provisions that, unlike the Aged Care Act, are not focused on any particular service sector. Rather, it is a general mechanism that enables investigations and conciliation in cases of age discrimination, though not elder abuse specifically (Kaspiew et al., 2016).
States and territories
Australian states and territories have a comparatively greater involvement across a wider range of legal provisions and policy frameworks relevant to elder abuse than the Commonwealth. Laws relating to the protection of adults are primarily state/territory based, though they do not necessarily cover all aspects of elder abuse (Lacey, 2014). This includes laws relating, but not limited, to (Joosten et al., 2017; Kaspiew et al., 2016):
- powers of attorney
- guardianship and administration
- criminal justice (e.g. theft, assault)
- estate planning
- property law.
The Australian Law Reform Commission has recommended the introduction of adult safeguarding laws in Australian states and territories that respond to a broader range of vulnerable adults than currently exist but has not recommended any additional criminal offences relating specifically to elder abuse (ALRC, 2017).
Australian policy frameworks
In March 2019, the Council of Attorneys-General released its National Plan to Respond to the Abuse of Older Australians (Elder Abuse) 2019-2023 (the National Plan). This national policy framework was developed in response to a key recommendation of the ALRC's report, Elder Abuse - A National Legal Response (ALRC, 2017). See Box 5 for more information about the principles guiding the ALRC's recommendations to address elder abuse in Australian policy and practice.
The National Plan outlines five priority areas of action:
- enhancing our understanding
- improving community awareness and access to information
- strengthening service responses
- planning for future decision making
- strengthening safeguards for vulnerable older adults.
These priority areas of action include a range of key initiatives for Australian governments to pursue in response to the abuse of older people. See the National Plan for more information.
In 2017, the ALRC (2017) published its final report on the inquiry into Protecting the Rights of Older Australians from Abuse. The inquiry covered a range of legal and policy issues relating to elder abuse, including aged care, enduring appointments, family agreements, superannuation, wills, banking, guardianship and financial administration, disability, social security, criminal justice responses and safeguarding adults at risk.
As part of its inquiry, the ALRC made a series of recommendations that aimed to balance two guiding principles:
- dignity and autonomy
- protection and safeguarding.
These principles recognise both the capabilities and agency of older people, while also recognising that various measures are needed to protect and safeguard some older people at increased risk of abuse. Policy and practice responses to elder abuse are, therefore, presented with challenges to balance these principles to both respect an older person's dignity and autonomy with regard to decision making and participation, while also implementing preventative measures that help protect and safeguard older people from potential abuse or neglect. See the ALRC report for more information.
State and territory policy frameworks
Most Australian states and territories have established policy frameworks for the prevention and intervention of elder abuse. These frameworks tend to sit within health or social services portfolios, though increasingly aim to sit across a range of relevant portfolios, such as the NSW Government interagency policy for preventing and responding to abuse of older people. Table 3 summarises the state and territory government policy frameworks in place at the time of writing.
Source: Table adapted and updated from Kaspiew et al. (2016) and Joosten et al. (2017)
Education and awareness strategies
Education and awareness strategies aim to increase a target population's knowledge and understanding of elder abuse as an early intervention to prevent its occurrence. Education programs are usually targeted to specific populations, such as older adults, potential perpetrators and professionals (Moore & Browne, 2017). Moore and Browne (2017) reviewed a range of education programs that target older adults, professionals in community settings, residents and staff in institutional settings and perpetrators, noting that the evidence supporting these prevention strategies is mixed.
Some evidence-based practices have demonstrated that education programs have increased participants' knowledge and skills in ways that have improved responses to elder abuse, such as increased reporting of abuse by professionals or increased self-esteem and wellbeing reported by older adults (see also Baker et al., 2016). However, there is currently no evidence that demonstrates their effectiveness in preventing or reducing the occurrence of elder abuse (Baker et al., 2016).
Box 6: Barriers to reporting elder abuse
Older people and professionals can face a range of barriers to reporting elder abuse to the appropriate service providers or authorities, depending on the nature of the abuse. For older people, barriers can include (Jackson & Hafemeister, 2016; Norris et al., 2013):
- fear of reporting
- fear of retaliation
- embarrassment and shame
- concerns about consequences for abusive adult children if reported.
For both older adults and professionals, abuse (particularly financial abuse/exploitation) may go undetected (Bagshaw et al., 2013). For professionals, barriers to recognising and reporting abuse may include (Hirst et al., 2016):
- reluctance to acknowledge the abuse
- limited knowledge or lack of protocols to identify abuse
- fear of liability
- lack of appropriate support services that could respond if reported.
Hirst and colleagues (2016) summarise key elements of effective education programs in health care settings based on their review of the literature. In principle, effective education programs for health professionals should comprise the discussion of ethical issues and professional/legal responsibilities in responding to cases of suspected abuse, training strategies that increase knowledge about elder abuse and the ability to modify attitudes that condone abuse (Hirst et al., 2016).
Secondary interventions target particular at-risk populations to prevent or intervene early to reduce the incidence of elder abuse and its harmful impacts. The main kinds of secondary interventions for elder abuse (Day et al., 2017; Dong, 2015; Hirst et al., 2016; Moore & Browne, 2017) include:
- screening and risk assessment strategies
- social support and capacity building strategies.
Screening and risk assessment strategies
Screening and risk assessment strategies perform an important role in both the prevention and intervention of elder abuse, and are typically implemented in health care settings (Dong, 2015; Hirst et al., 2016). Risk assessment strategies aim to screen an older person for known risk factors, assess their risk of abuse and help determine what actions should be taken in response (Moore & Browne, 2017). Moore and Browne (2017) note that the majority of risk assessment tools for elder abuse lack a rigorous evidence base but many demonstrate the status of either emerging or best practice. Hirst and colleagues (2016) summarise key elements of effective screening and risk assessment strategies in health care settings, which they argue should include a multifaceted approach to assessment, be conducted routinely in health care settings, and employ the skills of a team of experts.
Social and other support strategies
Prevention strategies that provide social support are broader in scope than education programs or risk assessment strategies. Some of the more common social support strategies include caregiver/family support services, financial management programs, legal assistance and elder abuse helplines (ALRC, 2017; Pillemer et al., 2016). Caregiver support may be offered in the form of housekeeping, respite care or support groups that aim to reduce caregiver burden or stress in an effort to prevent elder abuse. Pillemer and colleagues (2016) suggest that there is some evidence for the effectiveness of caregiver support programs as a strategy to prevent elder abuse. Similarly, there is some evidence to suggest that financial management programs targeted to at-risk older adults may help prevent financial abuse (Pillemer et al., 2016). Elder abuse helplines that offer advice and referrals to older people and family members are similarly supported by limited, but positive, evidence that suggests that they may be effective in preventing abuse (Pillemer et al., 2016).
Box 7: Social support as a key protective factor
Social support has emerged as one of the strongest protective factors identified in elder abuse studies (Acierno et al., 2017; Hamby et al., 2016; Pillemer et al., 2016). Social support in response to social isolation and poor quality relationships has also been identified as a promising focus of intervention because, unlike some other risk factors (e.g. disability, cognitive impairment), there is greater potential to improve the negative effects of social isolation (Hamby et al., 2016).
Tertiary interventions aim to address the incidence and impact of elder abuse after it has occurred and typically target either older adults who have been victims of abuse or the perpetrators of abuse.
Tertiary interventions responding to elder abuse face some serious challenges. The complexity of elder abuse in its multiple and diverse forms prevents a one-size fits all approach to intervention (Joosten et al., 2017). Consequently, many researchers have argued that interventions should address particular forms of elder abuse, rather than elder abuse as a general phenomenon (Dong et al., 2013; Hirst et al., 2016; Jackson & Hafemeister, 2016).
Interventions are further hampered by a general lack of evidence about what works to effectively address elder abuse and respond to the needs of its victims and/or perpetrators (Baker et al., 2016; Day et al., 2017; Dong et al., 2013; Hirst et al., 2016). Beyond these challenges and in recognition of the complex forms that elder abuse can take, others have suggested that interventions should incorporate an understanding of poly-victimisation that is client-focused (rather than incident-focused) and trauma-informed (Heisler, 2017).
Elder abuse intervention strategies typically focus on either older people, caregivers/perpetrators or family relationships (Joosten et al., 2017). An overview of the main kinds of interventions that target each of these population groups is provided below.
Interventions targeting older people
While the evidence is still emerging, some researchers have argued that multidisciplinary and coordinated intervention approaches are needed to respond to the complexities of elder abuse (Chesterman, 2016; Day et al., 2017; Hirst et al., 2016; Joosten et al., 2017). Multidisciplinary interventions bring together various combinations of social, legal, health and mental health professionals to provide holistic and tailored responses to particular forms of elder abuse. Multidisciplinary approaches to risk and needs assessment and referral operate in a similar way by drawing upon various expertise to ensure comprehensive identification of an older person's potential risks and needs (Joosten et al., 2017). Such approaches are designed to respond to the range of unique needs of older people who have been victims of one or more forms of abuse.
Case management and advocacy interventions may also involve multidisciplinary responses but, rather than being managed by a team, are facilitated by a case manager to assess an older person's needs and assist them to access other support services (Joosten et al., 2017). Motivational interviewing is a practice technique that aims to assist older people with decision making in relation to desired responses to cases of elder abuse, which may be effective in helping resolve an older person's feelings of ambivalence towards taking action (Joosten et al., 2017).
Other interventions for which the evidence is still emerging include elder abuse helplines and emergency shelters. Based on their review, Pillemer and colleagues (2016) found some evidence to support the use of elder abuse helplines that aim to help advocate for an older person by providing advice and assistance to refer to other support services. Emergency shelters that cater for the unique needs of older adults living in unsafe environments are another intervention for which the evidence is still emerging and will need further evaluation to demonstrate its efficacy (Pillemer et al., 2016).
Interventions targeting perpetrators
Interventions that focus on caregivers who have perpetrated abuse are less common than those focused on victims of abuse. Consistent with other prevention and intervention strategies, there is very limited evidence to support particular caregiver/perpetrator interventions, particularly with regard to reducing the occurrence of elder abuse and its related harms (Baker et al., 2016). However, there is some evidence to support some psychological approaches to caregivers/perpetrators (Joosten et al., 2017; Pillemer et al., 2016), including psycho-educative support groups for caregivers, anger management for caregivers and counselling for perpetrators. The positive results that some of these interventions show relate primarily to improved knowledge or reduced anxiety or depression for caregivers but do not relate to a reduction in incidents of elder abuse itself (Baker et al., 2016; Joosten et al., 2017).
Interventions targeting families
Interventions that focus on family relationships include family mediation, family care conferences and family-focused psychological or counselling approaches (Joosten et al., 2017). In Australia, these interventions mainly operate at a tertiary level, but it should be noted that they are sometimes implemented as secondary prevention measures.
These kinds of interventions are relatively new approaches to addressing elder abuse, with little research to demonstrate their effectiveness in reducing the incidence or impacts of elder abuse. However, given the importance of family relationships in moderating the risk of elder abuse, some have argued that family-focused approaches to elder abuse prevention and/or interventions should be explored further (Joosten et al., 2017).
Family mediation, facilitated by a trained professional, may be useful to help resolve family conflicts relating to care needs and financial matters (including inheritance disagreements), which may help reduce the risk of elder abuse. However, such approaches might not be appropriate in cases where elder abuse or family violence is being perpetrated. Family care conferences are run in similar ways to family mediation but focus on facilitating collaboration and communication between family members rather than aiming to resolve family conflict. Finally, psychological or counselling approaches that use family-based cognitive behavioural social work also show some promise in their ability to reduce the risk of perpetration among family caregivers, though more research is needed (Joosten et al., 2017).
Summary of prevention and intervention strategies
Policy and practice responses to elder abuse are still developing and are hampered by the lack of local evidence to inform and support particular strategies. However, there are promising policy initiatives currently underway, particularly the National Plan to Respond to the Abuse of Older Australians (Elder Abuse) 2019-2023, that aim to establish a more comprehensive and coordinated approach to responding to elder abuse in its complex forms. While the evidence to support prevention and intervention strategies is currently underdeveloped, available research on risk and protective factors for abuse provides a useful starting point for future developments in these areas. More research - including program evaluations - will be needed to establish an evidence base to inform future policy and practice development, particularly in relation to prevention and intervention strategies that target particular at-risk older adults at the community, organisational and programmatic levels.