Risk factors for elder abuse
This section draws on research literature - predominantly international population studies but also Australian studies where available - to outline emerging evidence on the various risk factors associated with elder abuse, with a focus on risk factors for victims and perpetrators, as well as relationship and contextual factors (see also the Appendix for a summary of risk factors associated with particular abuse types). While outlined in this way, these risk factors should not be seen in isolation. Rather, as research evidence suggests, the risk for elder abuse often involves a combination of factors associated with victims, perpetrators and contexts (Johannesen & LoGiudice, 2013). As Day, Boni, Evert, and Knight (2017) summarise:
Elder abuse is best conceptualised as resulting from a complex interaction between the victim and perpetrator, which is influenced by specific individual characteristics, the quality of the relationship, and the influence of the wider social and cultural environment. (p. 1532)
Box 3 outlines the main theoretical frameworks used to explain the complex interactions between various types of risk factors that contribute to elder abuse.
Theoretical frameworks help clarify the nature and dynamics of elder abuse (Harbison et al., 2012; Jackson & Hafemeister, 2016). In particular, they help make sense of the range of potential risk factors that may be involved in elder abuse, how they might interact, and the kinds of prevention and intervention strategies needed to respond.
Three of the main theoretical frameworks for understanding elder abuse are:
- ecological framework
- life-course perspective
- human rights-based framework.
These frameworks are often used in conjunction with each other (Castle et al., 2015; Jackson, 2016b; McDonald & Thomas, 2013; Norris, Fancey, Power, & Ross, 2013). Other theoretical perspectives, such as carer stress theory, have been offered as explanations for particular forms of abuse but have tended to be too limited in their focus to accommodate the complexities of elder abuse (McDonald & Thomas, 2013; Norris et al., 2013). These theoretical perspectives and others are often combined in complementary ways to provide a more holistic view of the complex dynamics of elder abuse (Jackson, 2016b).
An ecological framework focuses on the range of environmental contexts that influence the risk or occurrence of elder abuse (Schiamberg & Gans, 1999; von Heydrich, Schiamberg, & Chee, 2012). It comprises four inter-related environmental layers:
- an older person's immediate social environment (e.g. family)
- an older person's family relationships and other social support networks
- an older person's external social environments
- broader cultural values, norms and practices within society.
This framework provides an understanding of how various risk and protective factors operating at each level interact with each other. A bi-focal perspective is often applied to this framework to focus on the relationship between perpetrators and victims, rather than only focusing on the victims of elder abuse (von Heydrich et al., 2012). Figure 2 presents a simplified model of this bi-focal ecological framework.
Source: Diagram adapted from Johannesen and LoGiudice (2013)
A life-course perspective focuses on the intergenerational aspects of elder abuse, particularly how the history of family relationships and transitions to different life stages influence the risk of elder abuse (McDonald & Thomas, 2013; Schiamberg & Gans, 1999). This perspective provides an understanding of how early life events (e.g. child abuse, family violence or family conflict) can affect an older person's risk of abuse, including the quality of carer-care recipient relationships.
Human rights-based framework
A human rights perspective offers a normative framework to consider how broader social, cultural and legal factors can either inhibit or enable the enjoyment of an older person's right to dignity, autonomy and self-determination (ALRC, 2017; Biggs & Haapala, 2013; Dow & Joosten, 2012; Lacey, 2014). In this perspective, elder abuse is viewed as an issue of dignity and justice for older people that has broader social and systemic causes, such as age discrimination and loss of agency (Anand et al., 2013; Biggs & Haapala, 2013; Lacey, 2014; State of Victoria, 2016).
Risk factors for victims
There are multiple factors relating to an older person that can contribute to their risk of abuse. Cognitive impairment, functional or care dependency, psychological difficulties, lower income or poverty, problem behaviours, poor physical health and social isolation are some of the main factors associated with victims of elder abuse that have emerged from international prevalence studies (Dong, 2015; Dow & Joosten, 2012; Jackson & Hafemeister, 2016; Johannesen & LoGiudice, 2013; Kaspiew et al., 2016; Pillemer et al., 2016; von Heydrich et al., 2012). Other factors identified in prevalence studies include frailty, alcohol use, trauma or history of abuse, ethnicity (i.e. minority groups), relationship status, incontinence and personality traits (Burnes et al., 2015; Johannesen & LoGiudice, 2013; Ostaszkiewicz, 2017; Pillemer et al., 2016).
Box 4: A note about risk factors
Risk factors is a widely used term that refers to an association between a particular factor (e.g. social isolation) and an outcome (e.g. abuse). Risk factors do not usually demonstrate a causal relationship between things. For example, if cognitive impairment is a risk factor for elder abuse, it does not mean that cognitive impairment causes elder abuse.
In addition, risk factors identified in research are usually in relation to a particular study population (e.g. people aged 65 years and over living in Chicago, USA, in 2006) and, as such, do not necessarily translate to other populations or contexts. The reliability of particular risk factors between contexts generally depends on the strength of the association found and its consistency across different studies.
Cognitive impairment and disability
Cognitive impairment - including dementia - has consistently emerged as a strong risk factor for elder abuse across a range of empirical studies (Bagshaw, Wendt, Zannettino, & Adams, 2013; Dong, 2015; Fang & Yan, 2018; Johannesen & LoGiudice, 2013; Kaspiew et al., 2016). Deterioration in cognitive functioning, such as memory loss or confusion, limits an older person's ability to carry out routine tasks and self-care (Fang & Yan, 2018). As such, older adults with cognitive impairment are likely to require assistance with daily living from a caregiver, with more severe forms of impairment needing more intensive support. A heavy care burden may lead to caregiver stress and burnout that can exacerbate the risk of abuse of care recipients (Fang & Yan, 2018; Johannesen & LoGiudice, 2013). In addition, behavioural problems associated with dementia can cause conflict between the caregiver and the older adult, which may also lead to abuse (Fang & Yan, 2018).
Similar to the care or assistance needs relating to cognitive impairment, functional or care dependency is also associated with elder abuse (Dong, 2015; Johannesen & LoGiudice, 2013). This may be a result of physical function impairment (e.g. physical disability and frailty) that, as described above, limits self-care and creates situations of dependency, which can increase the risk of abuse.
Poor mental health
Where present, the poor mental health of older adults, such as depression and psychological distress, is a significant risk factor associated with abuse (Dong, 2015; Dong et al., 2013; Jackson & Hafemeister, 2016; McDonald & Thomas, 2013; Pillemer et al., 2016). Like other risk factors identified, poor mental health may co-occur with other factors that exacerbate the risk of abuse of older adults. Poor mental health may be associated with dementia or other forms of cognitive impairment, for example, and thus also be associated with care dependency (Fang & Yan, 2018). It may be both a result of past abuse and a risk for future abuse (Acierno et al., 2017; McDonald & Thomas, 2013).
Social isolation is another factor associated with the abuse of older people identified across a range of population and smaller scale studies (Acierno et al., 2017; Johannesen & LoGiudice, 2013; Kaspiew et al., 2016; von Heydrich et al., 2012). Researchers have suggested that social isolation creates a condition of vulnerability for older people due to limited access to social support, increased demands on caregivers, and less opportunities for abuse to be detected and reported by others (Kaspiew et al., 2016; von Heydrich et al., 2012). In a US population study, Acierno and colleagues (2017) found that low levels of social support were strongly associated with the mistreatment of older people in a US-based population study (see also Acierno et al., 2010). Conversely, a high level of social support was found to both reduce the negative impacts of elder abuse and be a protective factor against future abuse (Acierno et al., 2017).
History of abuse, family violence or conflict
A history of abuse, family violence and family conflict has been found to be a risk factor associated with some types of elder abuse, particularly physical abuse and neglect (Jackson & Hafemeister, 2016; Johannesen & LoGiudice, 2013; Kaspiew et al., 2016; McDonald & Thomas, 2013). This may be part of a continuation of abuse and conflict within family and intimate partner relationships that occurs over the life course (Kaspiew et al., 2016). McDonald and Thomas (2013), for example, found evidence that abuse experienced in childhood can increase the likelihood of experiencing abuse in later life. Similarly, Jackson and Hafemeister (2016) suggest that cases of neglect may be a consequence of poor child-parent relationships that have developed from insecure attachment in early childhood. In such cases, an adult child, who has a poor relationship with their parent and has reluctantly taken on a caregiving role, may lack the motivation and requisite skills to provide appropriate care for their older parent, which may lead to neglect.
Ethnic backgrounds (i.e. minority populations), low income, poverty and poor physical health are some of the other more frequently identified risk factors associated with victims of elder abuse to have emerged from population studies (Johannesen & LoGiudice, 2013; Pillemer et al., 2016). While some population studies have revealed broader demographic characteristics, such as ethnicity and poverty as risk factors for elder abuse, relatively little research has explored what causes or dynamics might be involved (Jervis et al., 2016). Jervis and colleagues (2016), for example, note that race/ethnicity is often associated with low income and poverty, and so caution against cultural explanations for increased risk of elder abuse among some ethnic minority populations. Where race/ethnicity has been found to be a risk factor even after controlling for other variables, Jervis and colleagues (2016) suggest further research is needed to determine the range of contributing factors, such as discrimination, that may be involved.
Risk factors for perpetrators
Less is known about risk factors associated with perpetrators of elder abuse than for victims (Pillemer et al., 2016). Based on available evidence, several factors have been identified that may contribute to the risk of individuals perpetrating elder abuse. Caregiver burden or stress, dependency on older person, sense of entitlement, drug and alcohol abuse, history of family violence or conflict, mental health difficulties (including psychiatric illness and psychological problems) are some of the main factors that may be associated with elder abuse (Jackson, 2016a; Jackson & Hafemeister, 2016; Johannesen & LoGiudice, 2013; McDonald & Thomas, 2013; Pillemer et al., 2016). The risk factors discussed below focus on attributes of the perpetrator but not on the type of relationship itself (e.g. spousal, parent-child, carer-care recipient relationships).
Caregiver stress has featured strongly in early theories about the causes of elder abuse (Jackson, 2016a). This has been supported to some extent in subsequent studies that have found caregiver stress to be a risk for elder abuse, particularly when providing care to older people with dementia or disability (Johannesen & LoGiudice, 2013). However, like other risk factors, this is likely to be the result of a combination of factors - specifically those associated with caregiver skills and capacity and an older person's aggressive behaviours that strain relationships between caregivers and older adults (Labrum, 2017; von Heydrich et al., 2012). In other words, the quality of relationships and other supports may moderate the negative effects of caregiver stress.
Financial or emotional dependency on older adult
Dependency on older people is a risk factor for elder abuse. Perpetrators of abuse are more likely to depend on an older person in various ways - emotionally, financially, housing - than non-perpetrators of abuse (Joosten et al., 2017; Pillemer et al., 2016). In some cases, such relationships of dependency have been described as 'parasitic', where an adult child with associated risks lives in a dependent relationship with their older parent (Jackson & Hafemeister, 2016). In these situations, an older person's risk of abuse may increase substantially. This can be exacerbated further in relationships of interdependency, where an older adult feels responsible for protecting an abusive adult child and may be less inclined to report incidents of abuse (Jackson & Hafemeister, 2016).
Poor mental health
Various studies have found poor mental health, including psychiatric disorders, to be a significant risk factor among perpetrators of abuse (Jackson & Hafemeister, 2016; Labrum, 2017; Pillemer et al., 2016). Poor mental health is more likely to co-occur with behavioural problems, substance abuse, dependency on older adults and relationship conflict that exacerbate the risk for elder abuse.
Alcohol and other drugs
Alcohol and substance misuse are risk factors for perpetrators of elder abuse (Jackson, 2016a; Johannesen & LoGiudice, 2013; Pillemer et al., 2016). Similar to the associations between perpetrators and poor mental health and dependency on older adults, it may be a combination of factors - as opposed to substance misuse alone - that can increase this risk (Jackson & Hafemeister, 2016). There is some evidence to suggest substance abuse is more closely associated with physical and emotional abuse than other forms of elder abuse (Moore & Browne, 2017).
Attitudes of entitlement
There is some evidence to suggest that family members' attitudes of entitlement contribute to the risk of abuse, particularly financial abuse (Bagshaw et al., 2013; Miskovski, 2014). In a small Australian study focused on financial abuse, Bagshaw and colleagues (2013) found that service providers and older people both reported that family members' sense of entitlement to an older person's assets was one of the main causes underlying emotional and financial abuse (see also Miskovski, 2014). Attitudes of entitlement are closely related to issues concerning ageism, which are discussed in more detail below.
Relationship and contextual risk factors
In addition to the risks associated with victims and perpetrators of abuse, there are also relationship and contextual factors that can contribute to the risk of elder abuse. These factors operate at the level of relationships, community and society.
Relationship risk factors
A range of relationship factors are associated with elder abuse, including the type and quality of relationships. Importantly, risks associated with relationship types do not necessarily represent entirely new sets of factors from those described above but rather a combination of factors associated with victims and perpetrators (Jackson, 2016a).
Different relationship types are associated with different forms of abuse (von Heydrich et al., 2012). For instance, family has been found to be the most common relationship type involved in overall cases of elder abuse in some population studies (Jackson, 2016a). In some studies, adult children have been found to be more likely to neglect their older parents than other perpetrators, with paid carers and spouses slightly less likely to neglect an older person's care than adult children (Jackson, 2016a). On the other hand, available evidence suggests that intimate partners are more likely to be physically and psychologically abusive than other perpetrators (Jackson, 2016a; Pillemer et al., 2016; Wijeratne & Reutens, 2016).
More generally, family conflict and poor relationships are strongly associated with elder abuse (Johannesen & LoGiudice, 2013; von Heydrich et al., 2012). In other words, the quality of relationships between older adults and their adult children can influence the risk of abuse, with an older adult's perception of the quality of family life being a good indicator of increased risk (von Heydrich et al., 2012). Some research has suggested that relationship quality and social supports are the most consequential factors influencing the risk of elder abuse (Johannesen & LoGiudice, 2013). This risk can be exacerbated when an adult child with other associated risk factors (e.g. problem behaviours, substance abuse, financial dependence) lives with their older parent (Jackson & Hafemeister, 2016). In some cases, this can be exacerbated further within relationships of interdependency if the parent feels responsible for the adult child and is unable to leave the abusive relationship (Jackson & Hafemeister, 2016).
Community-level risk factors
Community-level factors may affect other individual and relationship factors that increase the risk of elder abuse. In a study examining the influence of community-level factors on elder abuse, von Heydrich and colleagues (2012) found that alienation from community increases the risk for abuse, but that its impact was moderated by the quality of relationship between caregivers and older adults. The loss of friends for older people is another factor operating at this level that may increase social isolation, which can, in turn, limit access to social support and affect caregiver/older adult relationships. Formal social supports or networks for older people have been suggested as a key protective factor for older adults at risk of social isolation (Johannesen & LoGiudice, 2013).
Institutional care contexts
There is a lack of rigorous research relating to elder abuse in institutional care settings (Yon et al., 2018). However, based on the available research conducted internationally, it is likely that older people living in care institutions are at greater risk of experiencing mistreatment and may face different risks than older people in community settings (Castle et al., 2015; Fang & Yan, 2018), though this may not reflect the Australian experience. Some research suggests that the greater risk of abuse in institutional care settings may be the result of the cohabitation of other residents with associated characteristics that increase the risk of abuse (e.g. dementia, disability, problem/aggressive behaviours), opportunities for resident-to-resident abuse, unregulated restrictive practices, inadequate institutional resources, and carer stress, emotional exhaustion and lack of appropriate caregiver skills (Castle et al., 2015; Day et al., 2017; Office of the Public Advocate (Qld), 2017; Yon et al., 2018).
There is also some evidence to suggest that resident-to-resident abuse is the most prevalent form of abuse in institutional care settings (Castle et al., 2015). Similar findings also suggest that caregiving staff are vulnerable to aggressive or violent behaviours from older people in institutional care settings, which further exacerbates the risk of elder abuse that may result from retaliatory responses by caregiving staff (Castle et al., 2015; McDonald et al., 2012; Yon et al., 2018).
Culturally and linguistically diverse communities
Available research suggests that older people from culturally and linguistically diverse (CALD) communities may face additional risks of abuse as a result of increased social isolation, language barriers and greater dependence on family members (Office of the Public Advocate, 2006). There may also be cultural variations in understanding elder abuse, including differences in expectations of caring roles within families or attitudes towards reporting abuse and seeking assistance (Jervis et al., 2016; Roberto, 2016).
Aboriginal and Torres Strait Islander communities
There is very little research available in relation to the abuse of older Aboriginal and/or Torres Strait Islander peoples. However, there are some recognised differences between Indigenous and non-Indigenous understandings and experiences of elder abuse (Office of the Public Advocate, 2005). As a consequence of lower life expectancies for Aboriginal and Torres Strait Islander peoples, older people are generally defined as those aged 45-50 years and older (Kaspiew et al., 2016). There are also differences in terminology relating to the term 'elder', which in some Aboriginal and Torres Strait Islander communities is a title reserved for community leaders (Office of the Public Advocate, 2005). Differences in cultural understandings of relationships of trust, obligations to family and community members, and family structures mean that risks associated with the abuse of older adults in some Aboriginal and Torres Strait Islander contexts may be different from non-Indigenous contexts.
Societal risk factors
Some researchers have suggested that broader societal factors may create conditions that exacerbate the risk of elder abuse. However, little empirical research has been conducted that demonstrate the particular dynamics that may exist between societal factors and interpersonal abuse and neglect (Hamby et al., 2016; Pillemer et al., 2016). Societal factors may include (Kaspiew et al., 2016; Miskovski, 2014; Pillemer et al., 2016; von Heydrich et al., 2012; Weston & Qu, 2016):
- inadequate health and social services for older people
- economic pressures (e.g. affordable housing, intergenerational wealth disparities)
- intergenerational conflict.
In Australia, some have argued that overall wealth disparities between baby boomer and younger generations create conditions for intergenerational conflict, which can exacerbate risks of abuse - particularly forms of financial abuse (Kaspiew et al., 2016). In such cases, wealth disparities between generations may combine with ageist attitudes and lead to what Miskovski (2014) describes as 'inheritance impatience', whereby family members 'deliberately or recklessly prematurely acquire their ageing relatives' assets' (p. 18).