Elder abuse

Key issues and emerging evidence
CFCA Paper No. 51 – June 2019

What is elder abuse?

In Australia, elder abuse is typically defined as involving a form of mistreatment of an older person that occurs within a relationship where there is an expectation of trust (ALRC, 2017; Kaspiew et al., 2016). It can be in a range of forms, including physical, psychological, sexual, financial or social abuse and neglect. Perpetrators of elder abuse may include, but are not limited to, family members, friends, health and social welfare professionals, and formal and informal carers. Elder abuse can occur in a range of settings, including community-based and institutional care settings. However, despite some widely recognised definitions of elder abuse, there is no universal consensus on its definition (Kaspiew et al., 2016).

This section begins with a brief history of the concept in research and practice, before outlining some of the main issues involved in defining elder abuse, its prevalence in community and institutional care settings, its impact on victims and associated risk factors.

A brief history

The definition of elder abuse has been approached in various ways since the 1970s and has developed alongside changing social and historical contexts (Jackson, 2016b; Mysyuk, Westendorp, & Lindenberg, 2013). Beginning in the 1970s, early definitions of elder abuse focused on the physical abuse of female victims, known variously as 'granny battering', 'granny bashing' and 'granny battering syndrome' (Mysyuk et al., 2013). Early definitions narrowly conceived elder abuse as the physical abuse of older women. They carried with them assumptions of older women as vulnerable, burdensome and dependent on caregivers, with the abuse usually the result of caregiver stress (Jackson, 2016b).

In the 1980s, definitions of elder abuse were expanded to include a wider range of abusive behaviours (e.g. psychological and financial abuse) and potential victims, including older men (Mysyuk et al., 2013). The view that elder abuse was solely the result of caregiver stress was also challenged. Alternative theories, borrowing from developments in the field of family violence, focused on the perpetrators of abuse, rather than the victims' vulnerabilities or self-neglect (Jackson, 2016b). In the 1990s, broader definitions were proposed to include a wider range of potential perpetrators - not just caregivers - as well as recognising the wide range of contexts in which abuse may occur (Mysyuk et al., 2013).

Over recent decades, understandings of elder abuse have continued to develop to recognise that it is not a single phenomenon but a complex and diverse set of abusive behaviours. This is, in part, a recognition that there are many disciplinary perspectives that can be applied to its definition. As Jackson (2016b) argues, elder abuse is 'sometimes a crime, sometimes a medical issue, sometimes a social services issue, and sometimes a combination of these and more' (p. 5).

Rights-based perspectives have challenged traditional views that have assumed older people are primarily in need of protection and have instead promoted the need to recognise and respect the dignity and autonomy of older adults (Clare, Clare, Blunde, & Clare, 2014; Dow & Joosten, 2012; Harbison et al., 2012). At the same time, public health approaches have been applied to broaden prevention and response strategies in recognition of the various societal and community level factors that may be associated with the incidence of elder abuse (Kaspiew et al., 2016).

How is elder abuse currently defined?

One of the most widely accepted definitions of elder abuse, which is adopted by the World Health Organization (WHO),4 defines elder abuse 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. (WHO, 2008, p. 1)

This is a broad definition that covers a wide range of abuse types that many recognise as necessary for an adequate definition of elder abuse (ALRC, 2017; Qu et al., 2017). An important characteristic of this definition is its focus on the relationship between abuser and older person - a relationship defined by trust. In this sense, elder abuse defined this way can be characterised as a 'betrayal of trust' (Mysyuk et al., 2013, p. 55). While defined in this way, it remains an area of debate about what kinds of relationships include an expectation of trust (Qu et al., 2017). In its final report for the inquiry into Protecting the Rights of Older Australians from Abuse, the ALRC defines these relationships as those that:

include an expectation of trust as a result of an 'affective relationship', such as family members, friends, and informal carers, and those in a 'functional position of trust', such as paid carers and some professionals. (ALRC, 2017, p. 37)

In addition to this clarification, it is also important to highlight that this definition is not limited to the abuse of older people by younger people but also includes the abuse of older people by older people, such as spouses/partners. While not captured in this definition, some studies include the abuse of older people by their peers (e.g. older residents in institutional care settings).

In Australia, there is no nationally consistent definition of elder abuse (see Box 2). Definitions of elder abuse face a range of conceptual difficulties that arise in relation to the diversity of behaviours and experiences encompassed by the term 'elder abuse', debate about who should be considered as potential victims and perpetrators, and the kinds of policy and practice responses needed to address it. The main issues involved in defining elder abuse (ALRC, 2017; Harbison et al., 2012; Jackson, 2016b; Jackson & Hafemeister, 2016; Joosten, Vrantsidis, & Dow, 2017; Lacey, Middleton, Bryant, & Garnham, 2017; Mysyuk et al., 2013; Roberto, 2016) include:

  • Who should be included as potential victims (e.g. all adults over a certain age or particular 'at-risk' adults)?
  • What types of abuse should be recognised as elder abuse?
  • How does elder abuse relate to other forms of abuse (e.g. family violence)?
  • How do older people view elder abuse (e.g. older people's views may differ from the views of researchers, policy makers and practitioners)?

It is necessary to clarify these issues to understand what elder abuse is, the contexts in which it occurs and how it should be addressed in policy and practice. These issues are discussed below.

Box 2: Developing a definition of elder abuse for future research

As part of the Elder Abuse National Research project commissioned by the Australian Government, Attorney-General's Department, consultations about what constitutes elder abuse have been undertaken with a range of stakeholders. This project and earlier research (Qu et al., 2017) suggest there is broad consensus for a definition that is inclusive of a wide range of abuse types and potential perpetrators. More information about the Elder Abuse National Research Project is available on the AIFS website.

Older people or 'at-risk' adults?

There is some debate about whether potential victims of elder abuse should be defined by a particular age threshold or by a particular kind of vulnerability to abuse (i.e. 'at-risk' adults). Notably, the WHO definition of elder abuse does not define who counts as an older person. While WHO (2018) more generally defines an older person as someone aged 60 years or older, this age threshold may vary depending on the life expectancy and cultural understandings of particular populations. In Australia, where there is, approximately, a 10-year difference in life expectancies between Indigenous and non-Indigenous populations (AIHW, 2018), an older person is usually defined as someone aged 65 years or older (ABS, 2016b) for non-Indigenous people, and 45-50 years and older for Aboriginal and Torres Strait Islander peoples (Kaspiew et al., 2016).

There are other considerations relating to age as a defining feature of elder abuse. Some researchers and advocates have argued that, while particular risks for abuse increase as people get older (e.g. disability, cognitive impairment, frailty, limited mobility, etc.), these should not be seen as inherent to ageing itself (ALRC, 2017; Joosten et al., 2017; Moir, Blundell, Clare, & Clare, 2017). Rather, it is argued, elder abuse would be better conceptualised as relating to adults who are 'at-risk' of mistreatment, such as adults with cognitive impairment or who are socially isolated, which may make some people more vulnerable to abuse than others (ALRC, 2017). Such approaches to defining elder abuse seek, in part, to avoid characterising all older people above a certain age as vulnerable to abuse and neglect in the same ways. On the other hand, others have argued that defining elder abuse in reference to an age threshold is a valid approach because it captures a diverse set of capacities, vulnerabilities and experiences closely associated with ageing, even if these are not intrinsic to ageing itself (ALRC, 2017; Hamby, Smith, Mitchell, & Turner, 2016).

The tension between defining potential victims of elder abuse as 'older people' or 'at-risk adults' remains unresolved in research and policy literature. In Australia, there is an increasing recognition of the diversity of older populations in terms of older people's capacities, vulnerabilities and experiences (ALRC, 2017; Joosten et al., 2017). This has led to an emphasis on particular 'at-risk' adults in policies and practices that respond to elder abuse in its specific forms (ALRC, 2017), while definitions of elder abuse in research and theoretical literature have tended to retain their reference to age as a defining feature. Different terminology, therefore, may be needed for different purposes (e.g. referring to particular 'at-risk' adults when responding to particular forms of elder abuse; or referring to older people when discussing overall prevalence rates of elder abuse).

What types of abuse are considered elder abuse?

In policy and practice, elder abuse is generally recognised as one or more of the following five main types of abuse (ALRC, 2017; Kaspiew et al., 2016; Pillemer, Burnes, Riffin, & Lachs, 2016):

  • physical abuse
  • psychological or emotional abuse
  • sexual abuse
  • financial abuse
  • neglect.

Table 1 provides an example of how the main types of elder abuse can be defined, as provided in the National Plan to Respond to the Abuse of Older Australians (Elder Abuse) 2019-2023 published by the Attorney-General's Department. Definitions of elder abuse types may vary between jurisdictions. Readers are encouraged to refer to how elder abuse is defined within their state or territory and as it applies to their practice.

Table 1: Example of elder abuse definitions by type
Abuse type Definition
Physical abuse An act that causes physical pain or injury to an older person. It can include, but is not limited to, actions such as hitting, pushing or kicking. Inappropriate use of drugs or physical restraints is also an example of physical abuse.
Psychological or emotional abuse An act that causes emotional pain or injury to an older person. It can include insulting or threatening a person, acts of humiliation or disrespect, and controlling behaviours including confining or isolating a person.
Sexual abuse Any sexual behaviour without a person's consent. It includes sexual interactions and non-contact acts of a sexual nature.
Financial abuse The misuse or theft of an older person's money or assets. It can include but is not limited to, behaviours such as using finances without permission, using a legal document such as an enduring power of attorney for purposes outside what it was originally signed for, withholding care for financial gain, or selling or transferring property against a person's wishes.
Neglect The failure to meet a person's basic needs such as food, housing and essential medical care.

Source: Council of Attorneys-General (2019)

There is debate about whether there are additional categories of abuse and neglect distinct from the five main types outlined. Though less widely recognised as distinct categories, other forms of abuse may include social abuse, chemical/medical abuse, self-neglect and abandonment (Clare et al., 2014; Department of Health and Human Services, 2009; Jackson, 2016a; Rzeszut, 2017; SA Health, 2014). However, it may be considered that these types of abuse are already incorporated in the five main types defined above or, alternatively, are not within scope. For example, chemical/medical abuse is sometimes identified as a distinct form of abuse but may also be incorporated in to definitions of physical abuse or neglect (Hall, Karch, & Crosby, 2016). Abandonment may be identified as a distinct form of abuse or be incorporated in to definitions of neglect (Department of Health and Human Services, 2009). Social abuse that involves controlling and restricting an older person's movements and access to family and friends can also be considered a form of psychological/emotional abuse (ALRC, 2017).

In some policy frameworks, definitions of elder abuse explicitly exclude mistreatment that occurs within residential aged-care settings.5 However, most theoretical definitions do not exclude institutional care settings from among their potential contexts. In such institutional care settings, some types of elder abuse can manifest in pronounced ways. For example, restrictive practices that are sometimes used in residential care facilities - for example, seclusion, physical restraint or sedatives - may amount to the physical or psychological abuse of older people if used improperly or disproportionate to need (Office of the Public Advocate (Qld), 2017).

Adding to the complexity of conceptualising elder abuse as distinct types of abuse is the recognition that different forms of abuse can co-occur as a form of poly-victimisation (Heisler, 2017; Ramsey-Klawsnik & Heisler, 2014). Recent focus on poly-victimisation has highlighted the intersection of multiple forms of abuse as a pattern of victimisation, as well as the cumulative effects over the life course that can lead to abuse in older age (Hamby et al., 2016).

Poly-victimisation also highlights the potential severity of abuse experienced by older people (Burnes, Pillemer, & Lachs, 2017). Recent research has suggested that a substantial proportion of all elder abuse incidents are not single events but rather part of a series of abuse (Burnes et al., 2017). For example, in their analysis of elder abuse in the state of New York, USA, Burnes and colleagues (2017) found that most cases of emotional abuse and neglect occurred at least 2-10 times over a 12-month period, with around a quarter of all emotional abuse and neglect experienced 10 or more times.

How is elder abuse different to family violence?

Another consideration relating to the definition of elder abuse is its relationship to family violence and whether or not it should be seen as a distinct phenomenon. While elder abuse often occurs within a family context, it is generally recognised as a broader phenomenon than family violence (ALRC, 2017; Harbison et al., 2012; State of Victoria, 2016). Elder abuse may, however, be a form of family violence, insofar as it may occur within families and may share similar sets of risk factors (e.g. history of family violence, child abuse, substance abuse). In Australia, the Family Law Act 1975 (Cth) defines family violence as:

violent, threatening or other behaviour by a person that coerces or controls a member of the person's family (the family member), or causes the family member to be fearful. (s. 4AB(1))

This definition of family violence holds much in common with WHO's definition of elder abuse, discussed above, which defines abuse as a form of harm or distress caused to an older person. However, unlike family violence, elder abuse can occur outside family contexts and can be perpetrated by a wider range of potential abusers (Harbison et al., 2012; State of Victoria, 2016). In addition, the victims of elder abuse are typically identified as people aged 60 years and older or 65 years and older, whereas victims of family violence may be any age. Family violence, therefore, can sometimes be a form of elder abuse, and vice versa, but is not synonymous with it.

How do older people view elder abuse?

A final consideration relating to the definition of elder abuse concerns the views of older people. It is important to consider older people's views to ensure that research, policy and practice responses are not dominated by particular professional perspectives but are inclusive of older people's own experiences and understandings of elder abuse (Anand, Begley, O'Brien, Taylor, & Killick, 2013; Killick, Taylor, Begley, Carter Anand, & O'Brien, 2015; National Ageing Research Institute & La Trobe University, 2013).

Based on the relatively few studies conducted, older people have tended to view elder abuse in broader terms that are not limited to interpersonal acts of abuse or neglect. In a systematic review, Killick and colleagues (2015) found that older people conceptualise elder abuse both in terms of interpersonal mistreatment and as relating to broader social attitudes and expectations. At this level, elder abuse has been described in terms of intergenerational disrespect, loss of agency, limitation of social roles, social exclusion, age discrimination and systemic abuse (e.g. availability of appropriate public services) (Anand et al., 2013; Killick et al., 2015). The available evidence suggests that, for some older people, elder abuse is viewed as both a form of ageism that devalues their status and role in society and as an act of interpersonal abuse and neglect (Anand et al., 2013; Dow & Joosten, 2012; Harbison et al., 2012; Killick et al., 2015; Taylor, Killick, O'Brien, Begley, & Carter-Anand, 2014).

4 The definition of elder abuse used by the World Health Organization was originally developed in 1995 by the non-government organisation Action on Elder Abuse, based in the UK. See the Action on Elder Abuse website for more information: www.elderabuse.org.uk/Pages/Category/what-is-it

5 For example, Preventing and Responding to Abuse of Older People (Elder Abuse): NSW Interagency Policy; see www.facs.nsw.gov.au/download?file=591024