Elder abuse

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

3. What is known about the prevalence and dynamics of elder abuse?

This section considers evidence on the prevalence and incidence of elder abuse generally and of the different types of elder abuse that occur. The discussion establishes that there is very limited evidence in Australia that would support an understanding of the prevalence of elder abuse, and there is emerging recognition of the need for systematic research in this area (e.g., Elder Abuse Prevention Unit [EAPU], n. d.). There is some limited evidence on the incidence of elder abuse, mainly based on data derived from calls to state-based elder abuse helplines. There is also some international research on prevalence in different countries - the United States, the United Kingdom and Portugal, for example - but these studies have used different definitions and methodologies.

The discussion in this section first sets out the international evidence on prevalence and then considers what is known about the phenomenon in Australia.

The available evidence suggests that prevalence varies across abuse types, with psychological and financial abuse being the most common types of abuse reported, although one study suggests that neglect could be as high as 20% among women in the older age group (Australian Longitudinal Study on Women's Health [ALSWH], 2014). Older women are significantly more likely to be victims than older men, and most abuse is intergenerational (i.e., involving abuse of parents by adult children), with sons being perpetrators to a greater extent than daughters. For some women, the experience in older age of family violence, including sexual assault, represents the continuation of a lifelong pattern of spousal abuse (Cramer & Brady, 2013; Mann et al., 2014; UNDESA, 2013). Evidence on elder abuse occurring outside of a familial context (e.g., in care settings) is particularly sparse.

At the international level, the WHO (2015) recently reported that estimated prevalence rates of elder abuse in high- or middle-income countries ranged from 2% to 14%, with the following prevalence rates for the most common types of elder abuse:

  • physical abuse (0-5%);
  • sexual abuse (0-1%);
  • psychological abuse, above a threshold for frequency or severity (1-6%);
  • financial abuse (1-9%)
  • neglect (0-6%).

These prevalence estimates are based on data sources involving elderly people living in private and community settings and do not include those in institutional care or those with a cognitive impairment. These two latter limitations are characteristic of most prevalence studies, which therefore only reflect a partial view of the extent of elder abuse.

3.1 Prevalence studies

International

A US study based on 5,777 respondents (aged 60 and over), contacted through random-digit dialling in 2008, found that one in ten respondents had experienced elder abuse in the past year (Acierno, Hernandez, & Kilpatrick, 2010). The most common types of abuse were: financial abuse by a family member (5%), potential neglect (5%), and emotional abuse (5%). Physical abuse (2%) and sexual abuse (1%) were substantially less common.

A very different approach was taken in assessing prevalence in the UK Study of Abuse and Neglect of Older People (O'Keeffe et al., 2007). This study was based on face-to-face interviews with 2,111 people aged over 66 living in private settings across the UK in 2006. The study measured whether the participants had experienced mistreatment in the preceding 12 months at the hands of a family member, friend or care worker. Overall, 4% of the sample reported mistreatment in the defined period, comprising 4% of women and 1% of men. In this study, neglect (1%) and financial abuse (0.7%) were the most common forms of abuse, followed by psychological and physical abuse (each 0.4%). Sexual abuse was reported uncommonly (0.2% of women). The dominant relationship dynamic associated with abuse in this study was spousal, with 51% of perpetrators reported to be a spouse or partner, and married people more likely to report being abused compared to widows (9% cf. 1%). The other big perpetrator group was "another family member" (49%). Other reported perpetrators were care workers (13%) and close friends (5%).

A prevalence study from Portugal, based on a sample of 1,123 people aged over 60 living in private households, found that 12% had experienced elder abuse in the preceding twelve months (Gil et al., 2015). The relative distribution of the types of abuse were broadly consistent with the US findings, with financial and psychological abuse most common (6% each). Neglect was less common in the Portuguese sample (0.4%), though this may reflect the application of different definitions in the studies. Physical abuse was reported by 2% of participants, and sexual abuse by 0.2%. In this study, the largest group of defined perpetrators was ex-spouses or partners (14%), followed by sons and step-sons (13%), and daughters and step-daughters (6%). "Other relatives" accounted for incidents of abuse in 42% of cases, friends and neighbours in 16%, and paid professionals in 4%. One in five respondents refused to identify the perpetrators.

Australia

In Australia, there are two population-based studies that have yielded some insights into the extent to which older women experience violence, but there are limitations in the measures used and the extent to which they assess concepts relevant to elder abuse. One is a recently published, detailed analysis of data from the Personal Safety Survey (ABS, 2012a) by Australia's National Research Organisation for Women's Safety (ANROWS) (Cox, 2015). The age range for "older women" in that study was 55 plus, and the analysis was framed to assess violence against women, focusing on sexual assault by any perpetrator, and partner violence involving physical assault, physical threat, sexual assault and sexual threat by a cohabiting or intimate partner. In relation to cohabiting partner violence, 0.4% of women aged 55 and older reported this experience in the preceding 12 months (c. 12,800 women), compared with 3% of 25-34 year old women, the age group where this form of violence is most common. In relation to sexual assault, 0.2% of the sample aged 55 plus (c. 7,000 women) reported experiencing sexual assault in the preceding twelve months, against a national average rate across all age groups of 1%.

The other population-based study to yield approximations of prevalence of elder abuse (for women only) is the Australian Longitudinal Study of Women's Health (2014), which has measures relevant to vulnerability, coercion, dependence and dejection. This study is based on a random sample of women using a sampling frame from Medicare, with the oldest cohort (n = 5,561) being born between 1921 and 1926. When this cohort was surveyed in 2011 (at age 85-90), the findings suggested that 8% had experienced vulnerability to abuse, with name calling and put-downs being the most common forms. A similar level of prevalence was evident for this cohort in a preceding wave, conducted in 2008 (age 82-87), and slightly lower prevalence levels were found at younger ages (70-81 years). Measures the researchers used to assess neglect indicate a relatively stable prevalence rate of about 20% across waves, from ages 70-75 and 85-90 years.

Studies based on data from calls to helplines for elder abuse provide some further insights into the occurrence of elder abuse in Australia. There are three recently published sources from Queensland (Spike, 2015), Victoria (Joosten, Dow, & Blakey, 2015) and NSW (NSW Elder Abuse Helpline and Resource Unit, 2015). They reflect circumstances in which elder abuse is known or suspected and a person concerned has decided to seek advice on the situation.

In Queensland, calls to the EAPU helpline have increased substantially over the period that it has been operating, from just over 200 in 2000-01 to nearly 1,300 in 2014-15 (Spike, 2015; see further discussion in sections 3.2-3.4). The EAPU analysis of call data from the past five years provides a profile of the elder abuse concerns notified to the helpline. The calls were mostly in relation to female victims (68% female cf. 31 male cf. 1% unknown). The most common age group of victims was 80-84 years (23%), followed by 75-79 years (16%) and 85-89 years (15%). Perpetrators were male in 50% of calls and female in 45% (unknown: 5%). Where perpetrator age was known, the most common age group was 50-54 years (17%). Children were the largest groups of perpetrators reported (31% sons, 29% daughters). Otherwise, 10% were "other relatives", 9% a spouse/partner, and 21% fell into a combined category of neighbours, friends, workers and informal carers.

In 2014-15, the most commonly reported type of abuse to the EAPU helpline was financial abuse, accounting for 40% of reports, compared to 35% for psychological abuse, which had been the most common type up to 2012-13. The next most common types were neglect and social isolation, at about 10% each. Physical abuse was reported in just under 5% of calls, and sexual abuse was referred to in about 1% of calls. Where the perpetrator was a partner or spouse, the most likely form of abuse was psychological (41%). Where the perpetrators were adult children, financial abuse (39%) and psychological abuse (38%) were the most common types of abuse.

In Victoria, a recent study by the National Ageing Research Institute (Joosten et al., 2015), commissioned by Seniors Rights Victoria (SRV), was based on an analysis of data derived from records of calls to a helpline operated by SRV between July 2012 and June 2014. Of 755 calls, 455 involved discussion of a matter that raised elder abuse issues (including some that raised multiple types of abuse), and 236 raised issues not relating to elder abuse. The most common concerns raised in relation to elder abuse were about financial abuse (61%) and psychological or emotional abuse (59%). Physical abuse was raised much less frequently (16%), as were social abuse (9%), neglect (1%) and sexual abuse (0.4%). Elder abuse issues were most commonly reported in relation to female victims (73% females cf. 28% males) and the most commonly reported perpetrators were male (60% males cf. 40% females). The majority of perpetrators of the abuse reported to the SRV helpline were children of the victim (67%), with sons responsible for 40% of incidents reported, and daughters for 27%. Spouses were reported to be responsible in small proportions of cases (5% husbands and 3% wives).

In NSW, two years of call data (n = 3,388) to the NSW Elder Abuse hotline (NSW Elder Abuse Helpline and Resource Unit, 2015) reveal broadly similar patterns to the Queensland and Victorian data. Women were most commonly reported to be the victims (71% women cf. 28% men), and the most common age group of concern in the calls was 75-84 year olds (33%). In 71% of calls, the perpetrators were family members, and the largest group of perpetrating relatives were adult children (26% sons and 21% daughters). Just over one in ten (12%) of perpetrators were spouses. The most common abuse type reported in the calls was psychological abuse (57%), followed by financial abuse (46%), neglect (25%), physical abuse (17%) and sexual abuse (1%).

Three reports completed in the past five years (Clare et al., 2011; Miskovski, 2014; Wainer, Darzins, & Owada, 2010) have used data from a range of agencies to assess the extent and nature of elder abuse. The reports by Wainer, Darzins et al. and Miskovski specifically focused on financial abuse, and this kind of abuse emerged as the predominant concern in the report by Clare et al. Each of these reports illustrated the point that because responses to elder abuse are spread across different legal, policy and practice frameworks, the evidence available from these sources offers a piecemeal empirical understanding of elder abuse.

3.2 Risk factors and consequences

In the absence of systematic local research, insight into the factors that may mean older Australians are at higher risk of experiencing abuse, or the factors that may protect them against this risk is limited. As the discussion in the preceding section indicates, women are at higher risk of experiencing elder abuse than men (in part reflecting their greater representation in the older population; see further below). The literature indicates that there are different risk factors for different types of abuse. Among the common overall risk factors identified for which the empirical evidence is strong are when the older person has cognitive impairment or another disability, is isolated, or has a prior history of traumatic life events (Acierno et al., 2010; O'Keeffe et al., 2007; WHO, 2015). This section provides an overview of the main points that emerge from the literature on these issues.

Cognitive impairment or other disability

Cognitive impairment and other forms of disability are established in the research literature as having a strong association with being vulnerable to elder abuse (Acierno et al., 2010; Gil et al., 2015; WHO, 2015). The World Health Organization (2015) uses the term "intrinsic capacity" to refer to "all the physical and mental capacities" of an individual (p. 28), recognising that this varies across the life course and is influenced by a range of factors, including genetics (75%) and exposure to a variety of personal factors, such as socio-economic status. On average, intrinsic capacity peaks at age 20 and declines thereafter, with the rate of decline increasing from age 60. Compromised intrinsic capacity (as a result of conditions such as dementia or care dependence), which occur along a continuum ranging from low to severe, are associated with heightened risk of elder abuse, but are also a consequence of elder abuse (WHO, 2015). "Capacity", in a narrower sense, is a central concept in legal, medical and other responses to elder abuse, which recognises that there are degrees to which a person has capacity, and capacity may be present for some functions but not for others. In broad terms, capacity is the ability to make reasonable decisions. The link between cognitive impairment, which leads to reduced capacity, and elder abuse is well established (Acierno et al., 2010; Gil et al., 2015 & O'Keeffe, et al., 2007).

The Queensland EAPU analysis of helpline data (derived from calls made predominantly by family members and friends, but also from professionals) established that the incidence of abuse types observed varies according to whether the victim is reported to have dementia (Spike, 2015). Financial abuse is reported to occur at similar rates whether or not the victim has dementia, but psychological abuse (as a primary abuse type) occurs about half as often when the victim has dementia. This suggests that psychological abuse occurs to support financial abuse where dementia is not present, but is no longer necessary where dementia is present. Spike (2015) observed that "where financial motives are driving psychological abuse, once a victim has lost the capacity to manage their finances, psychological abuse becomes either: ineffectual as the victim no longer has the ability to direct their funds; or unnecessary because the perpetrator already has full access to the victim's assets". Miskovski (2014) observed the link between psychological abuse and financial abuse, noting that the former is a grooming behaviour for the latter.

Social isolation and traumatic life events

Social isolation has a well-established association with being vulnerable to elder abuse (Acierno et al., 2010; ALSWH, 2014; O'Keeffe et al., 2007; WHO, 2015). There are several dimensions to the connection between this condition and elder abuse. Isolation renders elders more vulnerable to exploitation for psychological, emotional and physical reasons, and it also means that abusive behaviour is less likely to be discovered due to the absence of social and other networks around the older person. Mariam, McLure, Robinson, and Yang (2015) explained the issues in this way:

As with most forms of abuse, access to the potential victim is a significant risk factor for the emergence of or continuation of elder abuse. Also in regard to living arrangements, social isolation has been shown to contribute to and result from ongoing abusive situations. Caregivers, family members and potential victims who lack substantial social networks experience increased demand on a limited number of caregivers and decreased social sanctions as a result of abusive behaviour, and they may avoid further social interactions out of shame or fear of discovery. (p. 20)

The association between experiences of elder abuse and previous traumatic events, including interpersonal and domestic violence, is evident in a range of sources (Acierno et al., 2010; Mann et al., 2014; UNDESA, 2013) and suggests elder abuse reflects the perpetuation of complex familial dynamics. Acierno et al. observed in their study that these experiences increased the risk of emotional, sexual and financial mistreatment. They suggested that:

there may be some shared variance between causes of these forms of mistreatment and precipitants of traumatic life events. On the most obvious level, interpersonal environments characterized by exposure to traumatic events are probably also more likely to contain abusive individuals over time. (p. 295)

There is a lack of detailed insight into the dynamics of intergenerational elder abuse in this context, and the extent to which elder abuse may be a response to the abusive adult child being abused or exposed to abuse in childhood involving the elder or other adults. Each of these dynamics is referred to in material emanating from practice perspectives on elder abuse,2 but empirical evidence is limited. A Canadian study examining prevalence and risk factors for "spouse abuse" at two different life stages (45-59 years, and 60 years and over) found slightly diminished rates of spousal abuse in the older sample, but a similar distribution between types of abuse (Yon, Wister, Mitchell, & Gutman, 2014). In the mid-age cohort, 9% experienced emotional/financial abuse, and 2% physical/sexual abuse. In the older cohort, the prevalence of emotional/financial abuse was 7%, and 1% for physical and emotional abuse.

Other factors

Other factors that have been established as risk factors for the perpetration of elder abuse include the perpetrator’s depression or alcohol and drug misuse, and the perpetrator being in a position of financial, emotional or relational dependence with the victim (WHO, 2015).

More generally, a theme that emerges from the analytic literature on elder abuse, but has not necessarily been directly measured in research, relates to attitudes and values (Gil et al., 2015; UNDESA, 2013; WHO, 2002a, 2015). As flagged at the outset, attitudes and values are associated with elder abuse in several different ways. Generally, social and individual values that fail to accord respect and consideration to elders and their human rights are considered to create an environment conducive to elder abuse (Peri, Fanslow, & Hand, 2009). Some literature points to an association between gender roles and elder abuse, particularly financial abuse, because under traditional gender role paradigms, women have not expected, or been expected, to take responsibility for financial matters. In this respect, norms that support women's relinquishment of financial control to others are also seen to be conducive to creating opportunities for elder abuse (Peri et al., 2009).

Consequences

Elder abuse has a range of physical, psychological and financial consequences. It can result in pain, injury and even death, and is associated with higher levels of stress and depression and an increased risk of nursing home placement and hospitalisation (WHO, 2015). Darzins, Lowndes, and Wainer (2009) referred to research suggesting that the effects of financial abuse on the elderly tend to be greater than on young people, as older people lack the capacity and time to recoup their financial losses, and those who suffer financial abuse experience "higher levels of psychological distress and depression than their peers … decline in physical health coupled with decreased resources for managing their healthcare" (p. 12).

Prevention

Preventative responses to elder abuse are generally seen to be underdeveloped in Australia. Directions in the themes underpinning thinking about prevention have two broad elements locally and internationally. The first is oriented toward changing the values and attitudes among the broader community and among professionals and individuals who interact with elders to address ageist (and sexist) assumptions and attitudes and to develop understanding of ageing processes, including potential cognitive decline. The second is oriented toward mitigating the risk factors for elder abuse, through measures to reduce social isolation, increase autonomy and empowerment, and support retention of control over financial affairs, or at the very least to help elders maintain knowledge of their financial affairs (e.g., Mariam et al., 2015; Wainer, Darzins et al., 2010). These issues are further discussed in section 7.

3.3 What is known about particular types of elder abuse?

Financial abuse

Of the different types of abuse identified in the preceding section, financial abuse is the most well researched in Australia. Evidence is sparse on the other kinds of abuse, although there is one recent qualitative study on sexual abuse and older women. There is little research on psychological abuse and neglect, although, as noted earlier, there is some evidence that suggests psychological and financial abuse often co-occur, and that psychological abuse may be a form of "grooming for financial abuse" (EAPU, n. d.; Miskovski, 2014; Wainer, Darzins et al., 2010).

The WHO (2002a) defines elder financial abuse as "the illegal or improper exploitation or use of funds or resources of the older person" (p. 3). Darzins et al. (2009) estimated that this experience affects between 0.5% and 5% of older Australians. The forms that financial abuse takes are varied, and it is this kind of abuse that is most likely to come to the attention of professionals across various areas (including banking, law and the welfare sector) because it may involve transactions and engagement with institutions and organisations. Financial abuse covers a spectrum of behaviours, and a guide published by Seniors Rights Victoria describes it as existing "in the grey area between thoughtless practice and outright theft" (Kyle, 2012, p. 7).

Several studies and analytic reports have raised concerns about financial management practices that are risky from the perspective of both the elder whose finances are being managed and the person managing them. Assistance in managing financial arrangements may be informal or formal in nature, ranging from informal responsibility for banking and bill payments, to substantial responsibility for financial arrangements being assumed. The frameworks and instruments governing formal transfers of financial responsibility are those relating to enduring power-of-attorney instruments, which are executed when a person has capacity, and allow another person (the attorney) to take responsibility for financial matters. If an enduring power of attorney has not been executed and it becomes necessary for someone else to exercise responsibility for an elder's financial affairs, then application must be made to a guardianship board or tribunal. It appears that anticipatory execution of enduring power-of-attorney instruments is common, with one study of supported asset management identifying 69% of a sample of 421 Victorians aged 65 and over using an enduring power of attorney (Tilse, 2007, as cited in Wainer, Darzins et al., 2010).

In 2010, Wainer, Darzins, and Owada observed that "supported asset management is a common experience for family members and there is much work to be done to understand the dynamics of this form of care, particularly in a multi-cultural society" (p. 6). In this area, varying societal values about the extent to which assets are considered communal or personal within a family are evident, and it is also evident that expectations are culturally determined (Miskovski, 2014; Wainer, Darzins et al., 2010). The study by Wainer, Darzins and Owada was based on an analysis of data from a range of agencies whose operations bring them into contact with elder financial abuse in Victoria. The findings of this study, consistent with the discussion in section 3.2, showed that, to the extent data were available, between one- and two-thirds of the elderly concerned were vulnerable because of dementia. The interviews with professionals also confirmed that financial abuse was accompanied by psychological abuse that was intimidating, controlling and fear inducing. Among the ways in which financial abuse was carried out were through misuse of powers of attorney, coerced changes to wills, unethical trading in title to property, and the coercion of people without capacity into signing documents in relation to assets that would result in financial gain for the perpetrator. Concerns were also raised, particularly by professionals from helplines, in relation to situations where adult children were dependent on aged parents for accommodation or financial support by reason of addiction or mental ill health, but failed to fulfil reciprocal expectations in relation to caregiving activities. Another area where financial abuse was identified was where an adult child held power of attorney and was also the beneficiary of a will and acted to preserve their inheritance by not selling the family home to release funds for an assisted accommodation bond, even though this was needed for their parent. Another analysis of the circumstances in which concerns about financial abuse arise indicated that in some circumstances adult children holding powers of attorney may use this power to gain pre-mortem control over heritable property and exhaust the resources in the estate, to the disadvantage of the other beneficiaries (Miskovski, 2014).

Wainer, Darzins et al. (2010) concluded that the legal system was rarely used and unhelpful when trying "to prevent or remedy financial abuse". There were a number of reasons for this, including privacy issues and the lack of an easily identifiable and accessible mechanism for reporting concerns. These findings are consistent with those of a multi-dimensional study by Tilse et al. (2005) on practices surrounding the management of older people's assets. The research found poor understanding of legal obligations and mechanisms in relation to assisted asset management among elder people and those caring for them. It also highlighted "attitudes that suggest entitlement" to the older person's assets, that together with risky asset management practices, created the conditions for financial elder abuse. Concluding that legal redress is often unattainable for practical reasons (assets are unrecoverable) or personal reasons (the older person decides that maintaining relationships is more important than pursuing justice), the researchers highlighted the need for a cross-sectoral approach involving financial institutions, advocacy organisations and agencies concerned with providing services to older people.

Bagshaw and colleagues (2013) examined in separate surveys the views of 209 service providers on the risk factors for elder financial abuse, and the concerns of 114 older people and their family members about financial abuse. Six risk factors were identified by majorities of services providers:

  • a family member having a strong sense of entitlement to an older person's property or possessions (84%);
  • an older person having diminished capacity (82%);
  • an older person being dependent on a family member for care (81%);
  • a family member having a drug or alcohol problem (73%);
  • an older person feeling frightened of a family member (73%); and
  • an older person lacking awareness of his or her rights and entitlements (72%).

About half of the sample of older people and their family members indicated they did not have concerns about financial management issues. The balance indicated they were "somewhat concerned" (30%), "concerned" (8%) or "very concerned (18%).

Sexual abuse

As the prevalence and helpline data set out in section 3.1 indicate, sexual abuse appears to be an uncommon form of elder abuse; however, the ANROWS analysis of Personal Safety Survey data suggests it is potentially experienced by thousands of older women annually.

Empirical evidence in this area is limited, but a recent study by researchers at La Trobe University has shed some light on the issue. Mann and colleagues (2014) conducted a study involving professionals concerned with sexual assault, service providers in aged care services, and women over 65 who had experienced sexual assault, their family members and friends. The findings showed that "the sexual assault of older women occurs in a wide range of contexts, settings and relationships. Older women remain vulnerable to sexual assaults by husbands/partners and family members. They can also face threats from service providers that they may rely on for general care, health care and intimate care. Assaults in such settings can be perpetrated by female as well as male staff" (p. 2). The research highlighted a lack of mechanisms to ensure that professionals such as personal care workers were fit for the responsibilities of working with the aged, and suggested a need for licensing of these workers and a way of conducting background checks analogous to the Working with Children Checks that are required for people who work with children (Child Family Community Australia, 2014). It also revealed mixed views on the question of reporting obligations, with evidence of some support among professionals for mandatory reporting. Concern was expressed in relation to gaps in reporting obligations. Most significantly, the research highlighted the fact that no statutory reporting obligations apply in aged care services that do not receive Commonwealth government funding. The researchers also expressed concern about the narrow statutory reporting obligations in the Aged Care Act 1997 (Cth) in relation to Commonwealth-funded facilities, and the implications of the discretion not to report (where reporting would otherwise be mandatory) in circumstances where the reportable act is committed by a person with cognitive impairment.

3.4 Elder abuse in particular contexts

As with elder abuse in general, insight into elder abuse in particular contexts is limited, including among Aboriginal communities, culturally and linguistically diverse (CALD) communities, rural communities, and gay, lesbian, bisexual, transsexual, intersex and queer (GLBTIQ) communities (Higgins, 2004). As the dynamics of elder abuse are context dependent, there remains much to be understood about the extent to which the dynamics of elder abuse are different or similar in varying contexts, and the extent to which different responses may be required.

In relation to elder abuse in Aboriginal communities, a 2005 report by the Office of the Public Advocate in Western Australia established that in the Aboriginal context, even at the level of terminology, the conceptualisation of the mainstream concept of elder abuse requires reconsideration. Both the terms "elder" and "abuse" were considered problematic, as "elder" has a specific meaning in Aboriginal communities, and "abuse" may be considered inapt and confrontational. The research indicates that, as in the non-Aboriginal context, the most common type of abuse is financial but that other types of abuse also occur. Two factors that were identified as having particular implications in the Aboriginal context were cultural obligations and the circumstances of grandparents. From a cultural perspective, Aboriginal norms in relation to reciprocity, the expectation that resources will be shared, and kinship (where a wide variety of relationships are involved in familial and community networks), are dimensions that complicate understandings of whether and how elder abuse is occurring. The extent to which calls on grandparent resources to care for grandchildren are culturally reasonable or unreasonable was also highlighted by the research. Substantially more work is required to understand and conceptualise elder abuse in the Aboriginal context, especially among different groups in different circumstances, given the diversity among Aboriginal and Torres Strait Islander communities.

In CALD communities, the literature suggests that a number of factors can heighten vulnerability to abuse, including language difficulties for those whose primary language is not English, social dependence on family members for support, and the potential conflict caused by cross-generational expectations in relation to care (Bagshaw et al., 2009). Two studies have shed some light on these issues, although of course the extensive range of cultures represented in our community, the spread of religious and cultural values, and the diverse range of settlement and migration pathways and timeframes mean that a complex range of dynamics will be relevant in different families and communities. A study by Wainer and colleagues (2011) examined practices in Greek, Italian and Vietnamese communities in relation to asset management, enduring power of attorney instruments and wills, and knowledge about elder abuse. The research highlighted similarities and differences between these groups in their awareness of and attitudes to elder financial abuse, and in relation to assisted asset management should that become necessary. All three groups had an awareness of elder financial abuse, and Italians were more likely than the other groups to know of examples of this. Greeks were most likely to believe elder financial abuse to be common, and the Italians and Vietnamese were least likely to believe this. All three groups intended to rely on family members for assistance with asset management should they be unable to manage this themselves. The use of wills and enduring powers of attorney was high among Italian and Greek participants, but not the Vietnamese.

In a focused case study exploration, Zannettino, Bagshaw, Wendt, and Adams (2015) documented one account where a mother, born in a northern European country, was reported by her son to have been isolated from her other children by her abusive daughter. One consequence of the abuse was that the mother was coerced into signing a will leaving the majority of the estate to the abusive daughter. The authors concluded that the case study demonstrates "the relationship between financial and emotional abuse in the context of CALD older people, whose isolation from the dominant culture may make them more dependent on family members and more vulnerable to abuse" (p. 82).

Some issues particularly pertinent to people resident in rural areas have been highlighted in the research (Tilse et al., 2006; Wainer, Lowndes, Owada, & Darzins, 2010). These include the complexity of assets held by families resident in rural areas such as farming properties; lack of access to services that may assist with asset management arrangements and responses to situation where elder abuse is occurring or expected; and the dynamics involved in reporting or disclosing elder abuse in rural communities, where shame and concern to protect the family name potentially play an inhibiting role. The rural participants in Wainer, Lowndes et al.'s study showed lower levels of confidence in their own ability to recognise whether an elder was experiencing financial abuse. Tilse et al.'s study highlighted the complex and potentially conflictual dynamics around farming properties with the multi-generational interests involved where the farm is the family business. These included complications about the treatment of farms as inheritance, and the balance between providing for children and maintaining the family business, placing one child in a different position from the others, and the treatment of labour and other contributions to the improvement of the farm in estates.

3.5 Dynamics in relation to disclosure and reporting

Complex dynamics and structures are relevant to consideration of the questions of disclosing, discovering and reporting elder abuse if it is disclosed or discovered. This section introduces some the issues raised in the empirical and analytic literature, with reporting obligations and mechanisms discussed more formally in section 6.

Empirical evidence on these issues is very limited in Australia. Elder abuse is generally considered to be remain hidden to a significant extent, and if it is disclosed or discovered, under-reported (Jackson & Hafmeister, 2015; UNDESA, 2013; WHO, 2002b). A range of issues is influential in this context, including difficulties in detecting and identifying elder abuse and the conditions within which it occurs. The same factors that are associated with vulnerability to elder abuse - social isolation and cognitive impairment - also militate against disclosure or discovery and reporting. Where abuse occurs in the context of familial or caregiver relationship dynamics (Jackson & Hafmeister, 2015), this may inhibit a parent disclosing mistreatment by a child and a spouse disclosing mistreatment by a partner. The dynamics of dependence are also relevant, since an aged person may be reluctant to disclose abuse by someone on whom they depend for care, since disclosure may mean withdrawal of the care and potentially an unchosen change in living circumstances. Cognitive impairment may also mean that an older person is unable to disclose or is not believed when they do disclose. Shame, embarrassment, fear of negative repercussions and/or a belief that disclosure and/or reporting may result in no consequences or negative consequences may also be relevant.

The question of reporting obligations in Australia is the subject of significant debate. Apart from limited obligations in relation to specific offences for Commonwealth-funded care facilities (Aged Care Act 1997 (Cth), s 63-1AA), there are no statutory mandatory obligations on professionals to report elder abuse (see section 6.1). Reporting pathways are acknowledged to be complex and confusing both for members of the community and professionals. Duties in relation to reporting depend on the professional context in which elder abuse is discovered. Some analyses have shown that even professionals providing care and other services to elders are unaware of reporting mechanisms (e.g., Miskovski, 2014).

There are a number of different perspectives on the question of whether mandatory reporting obligations should be introduced. One view is that mandatory reporting is paternalistic and detracts from the autonomy of the elder involved. This position is predicated on the view that the elder is in the best position to make a decision about whether abuse should be reported, and derogating from this position reflects an infringement of their human rights, particularly the right to self-determination (EAPU, 2006). Although some organisations and individuals suggest that mandatory reporting might be an appropriate response where elders have diminished capacity, the EAPU asserts that existing obligations arising from professional duty of care requirements already impose sufficient reporting requirements on professionals.

Research suggests mixed views among professionals. The Alzheimers Australia NSW (Miskovski, 2014) study found some support for mandatory reporting of financial abuse among professionals. The study by Mann et al. (2014) on sexual assault and older women also found support among some professionals for mandatory reporting of sexual assault in this context, but this was not a universal view. Mann and colleagues summarised the complex issues that arise in this context in this way:

Such accounts highlight complex ethical, legal, managerial and practical dilemmas and they point to tensions between rights and responsibilities. They also raise issues that extend beyond the residential care sector, suggesting the need for a wider response that encompasses the spectrum of settings in which older women live (p. 53).

A study from the US that interviewed victims and case workers from an adult protective service to examine the dynamics of detection and disclosure showed that relationship factors were an important influence in whether elder abuse was: (a) detected, and (b) reported (Jackson & Hafmeister, 2015). This indicates that where there is a close relationship between the victim and perpetrator, abuse tends to be reported only when it reaches a high threshold of severity. Abuse is more likely to be reported when the victim-offender relationship is not close; for example, when the abuse is being committed by a care worker. The study also found that the relationship between the victim and the person reporting the abuse is relevant, with superficial connections - such as when the reporter is a professional rather than a family member - resulting in reports occurring more readily.

2 See, for example, the EAPU web page on risk factors: <www.eapu.com.au/elder-abuse/risk-factors>.