Elder abuse

Understanding issues, frameworks and responses
Research Report No. 35 – February 2016

2. What is elder abuse?

Varied conceptualisations of elder abuse are evident in different frameworks and disciplines (United Nations Department of Economic and Social Affairs [UNDESA], 2013). One of the dominant disciplines in the field has been social gerontology, which is concerned with the study of ageing. Human rights and public health perspectives are also evident, and intersecting fields of thinking and concern include those related to family violence, violence against women, and disability. An approach informed by an older adult protection philosophy arising from the discipline of geriatrics in medicine has influenced some approaches in the United States, including the establishment of adult protective services (UNDESA, 2013; also see section 8.2). In Australia, approaches of organisations concerned with elder issues, such as COTA Australia (the peak national organisation representing the rights, needs and interests of older Australians), tend to be informed by human rights conceptualisations that emphasis self-determination, autonomy and respect (Department of Health, Victoria, 2012).

The way in which elder abuse issues and responses are approached depends on the perspective adopted. The WHO takes a public health perspective, adopting a 1995 definition developed by Action of Elder Abuse UK to describe 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. 6). This is the definition adopted in some Commonwealth frameworks in Australia (e.g., MyAgedCare). A working definition put forward by the US Centers for Disease Control and Prevention (CDC; 2015), again from a public health perspective, is more specific: "an intentional act or failure to act by a caregiver or another person in a relationship involving an expectation of trust that causes or creates a risk of harm to an older adult" (defined as someone age 60 or older). It also provides working definitions of specific types of abuse (see Appendix).

A commonly applied definition locally is that adopted by the Australian Network for the Prevention of Elder Abuse in 1999 (also based on the Action of Elder Abuse UK definition), which specifies that elder abuse is:

any act occurring within a relationship where there is an implication of trust, which results in harm to an older person. Abuse may be physical, sexual, financial, psychological, social and/or neglect.1

Although these definitions have similar elements, the absence of a precise agreed definition is considered problematic for a range of reasons, not the least of which is the difficulty in measuring elder abuse. One important area where this is evident is in relation to the age at which one might be considered an elder. For the purpose of the WHO and CDC definitions, 60 is the defining age. In Australia, however, for statistical and range of other purposes, including access to the pension (Australian Bureau of Statistics [ABS], 2012b), 65 is the starting point for status as an "elder", and 70 is the age for access to aged care services (Cotterell, Leonardi, Coward, Thomson, & Walters, 2015). The definition of "older" Australian used in this paper is consistent with that used by the ABS, which classifies people over 65 as "older". It should be noted, however, that some definitions, studies and services concerned with elder abuse use the age of 60 as a starting point. The literature on ageing also distinguishes between "old" people (65-84 years) and "old old" people, aged 85 and above (e.g., Wainer, Owada, Lowndes, & Darzins, 2011). The discussion in section 3 establishes that this is a useful distinction to make from a statistical viewpoint as there are significant differences in some areas between these age groups. For Aboriginal and Torres Strait Islander peoples, who have a substantially lower life expectancy than non-Indigenous peoples, a lower age for those who are "older" is considered appropriate (e.g., 45-50 years; Cotterell et al., 2015).

At a more complex level, as a "multi-faceted construct involving intentional and unintentional actions of both a passive and an active nature" (Clare, Blundell, & Clare, 2011, p. 44), consideration of the definition of elder abuse raises the fundamental question of what purpose the definition serves. A recent critique by a Western Australian research team (Clare et al., 2011) has raised several other concerns, arguing that, in addition to the age question, the term "elder abuse" needs to be fundamentally reconsidered. In addition to the operational complications arising from the application of different definitions in different legal, policy and practice frameworks in the Western Australian context, Clare and colleagues called for a debate on whether age should be the defining aspect of elder abuse, or whether it should be conceptualised on the basis of "an assessment of capacity for self-care and self-protection" (p. 40).

This analysis highlights an important issue in considering definitions, given that many of the behaviours captured by the definition may be experienced at any stage of the life course and are covered by various criminal and civil law frameworks. From a conceptual standpoint, this raises the question of whether harmful behaviours involving older people are distinguishable from harmful behaviours involving other adults because they involve older people or because they involve the exploitation of vulnerability. A further significant question that arises in this context is how, in such an analysis, issues such as the dynamics of dependence (section 3) should be dealt with.

Considering the phenomenon of elder abuse more broadly, theoretical models and approaches attribute its occurrence to a complex array of factors, including social and cultural attitudes to the aged. The international literature draws common links between the causes of and conditions for the occurrence of different kinds of abuse and maltreatment, including family violence, child abuse and neglect, and elder abuse (Wilkins, Tsao, Hertz, Davis, & Klevens, 2014; WHO, 2002b). Originally developed to support the conceptualisation of family violence prevention approaches, the socio-ecological model is also considered to be an apt approach in relation to elder abuse (WHO, 2002b). This model posits that interpersonal violence occurs as a result of interactions between factors at four levels of influence: individual, relationship, community and societal. In relation to violence against women across these four levels, attitudes inconsistent with the equality of women are associated with higher levels of family violence. An analogous approach is evident in relation to elder abuse, in which age discrimination and a lack of respect for elders are are societal factors associated with its occurrence (Gil et al., 2015; Hayslip, Reinberg, & Williams, 2015; Mann, Horsley, Barrett, & Tinney, 2014; WHO, 2002b). The authors of a recent prevalence study in Portugal noted that the findings of the study demonstrate that "prevalence rates vary by type of abuse, the victims socio-demographic characteristics, the victims' relationship with the perpetrator … The social responses toward victim protection and collective representations of this social problem, such as the belief systems, cultural norms, and social attitudes towards violence (e.g., higher or lower tolerance toward it) are structural dimensions that indirectly influence it" (Gil et al., 2015, p. 190).

Although different types of interpersonal violence are considered to have common elements in this theoretical model, a range of different theoretical and practice paradigms are applied in relation to each kind of violence. Responses to family violence, for example, have developed out of a feminist framework, and some Australian and American analyses have highlighted theoretical and practical tensions in responses to family violence involving women when feminist and gerontological approaches intersect internationally and locally (Bagshaw, Wendt, Zannettino, & Adams, 2013; Cramer & Brady, 2013). Similarly, analogies between child abuse and elder abuse are seen as problematic in some respects, as "making comparisons between elder abuse and child abuse, and drawing on responses used in child protection, is ageist and generally not appropriate" (Australian Association of Gerontology, 2015, p. 4). However, the structural and systemic issues raised by elder abuse, as highlighted in this and other reports, mean that recent experience in developing national approaches to child protection (the National Framework for Protecting Australia's Children) and family violence (the National Plan for the Reduction of Violence Against Women and Their Children) provide insight into the development of national approaches in relation to complex issues involving multiple levels of governments and a spread of different agencies.

Progress towards understanding elder abuse and developing effective response and prevention measures, are recognised to be considerably less well developed than in other areas of interpersonal violence, including family violence and child abuse (WHO, 2014). The following section outlines what is known about prevalence and risk factors internationally and locally.

1 See the Definition of Elder Abuse at: <www.arasagedrights.com/definition-of-elder-abuse.html>.