Elder abuse

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

8. What can we learn from international approaches?

International responses to elder abuse have generally been shaped around the evidence of risk factors for perpetration and victimisation (discussed in section 3.2), including the issues of care dependence, poor physical and mental health, low income and isolation (WHO, 2015). More particularly, responses have tended to reflect the recommendations of the WHO (2002b) World Report on Violence and Health, which called for stronger laws and policies and effective prevention strategies.

It is worth noting in this regard the WHO (2002a) Missing Voices report, which canvassed the views of older adults on ways in which to combat elder abuse. That report identified widespread agreement among participants that the prevention of elder abuse is a public responsibility. Strategies proposed by participants to address this issue included:

  • the provision of health services and supervision of care institutions;
  • the enactment of strong protective laws;
  • the development of awareness-raising campaigns to enhance respect for older people, and education strategies to empower older adults (particularly in relation to the management of their financial affairs);
  • the provision of training for professionals to recognise and respond to signs of elder abuse; and
  • the conduct of longitudinal research to improve knowledge of elder abuse.

The lack of research on the effectiveness of particular prevention strategies is a common theme in the elder abuse literature (e.g., Davidson, Rossall, & Hart, 2015). However, the WHO (2015) noted a number of case study examples supporting the effectiveness of several strategies, including:

  • using multidisciplinary teams where professionals pooled expertise to resolve cases of alleged elder abuse;
  • providing helplines and websites that provide information to potential victims;
  • monitoring by financial institutions for suspicious patterns to identify older adults at risk of financial abuse; and
  • conducting public campaigns to raise awareness of elder abuse and enhance respect for older adults.20

The following sections provide some international illustrations of these strategies.

8.1 Legislative responses

The WHO (2002b) noted that, at that time, few countries in the world had enacted specific legislation on elder abuse. Little appears to have changed in the intervening years. In its 2014 Global Status Report on Violence Prevention, which reported on the progress that countries had made in implementing the recommendations of the 2002 report,21 the WHO noted that of all types of violence, laws in relation to elder abuse were the least commonly reported, with only around 40% of countries reporting having enacted laws to prevent elder abuse.

More commonly, the abuse of older adults is addressed through provisions in general criminal laws and laws governing property rights and mental health (WHO, 2002b). A typical example in relation to property rights is Part 9 of the New Zealand Protection of Personal Property Rights Act 1988, which deals with enduring powers of attorney. This part includes sections that impose a duty on those with a power of attorney to "use the donor's property in the promotion and protection of the donor's best interests, while seeking at all times to encourage the donor to develop the donor's competence and to manage his or her own affairs in relation to his or her property" (s 97A(2)).

A number of jurisdictions also have provisions in their criminal law statutes that cover elder abuse. For example, New Zealand's Crimes Act 1961 imposes a legal duty on the carer of a "vulnerable adult" to "take reasonable steps to protect the that person from injury" (s 151). A vulnerable adult for this purpose is "a person unable, by reason of detention, age, sickness, mental impairment, or any other cause, to withdraw himself or herself from the care or charge of another person" (s 2).

More recently, some jurisdictions have enacted legislation to criminalise the abuse of vulnerable older adults. For example, Chapter 13 of the California Penal Code creates a number of elder abuse offences that can be prosecuted as a felony or misdemeanour, with penalties of up to four years' imprisonment on conviction.22 This includes the offences of willfully causing or permitting an elder or dependent adult "to suffer unjustifiable physical pain or mental suffering" and willfully causing or permitting an elder or dependent adult "to be placed in a situation in which his or her person or health is endangered".23 Section 368(a) contextualises the basis for these offences as follows:

The Legislature finds and declares that crimes against elders and dependent adults are deserving of special consideration and protection, not unlike the special protections provided for minor children, because elders and dependent adults may be confused, on various medications, mentally or physically impaired, or incompetent, and therefore less able to protect themselves, to understand or report criminal conduct, or to testify in court proceedings on their own behalf.

The criminal laws of some countries also contain provisions that require the courts to consider evidence that the offence had a significant effect on the victim due to their age, or that the offender in committing the offence abused a position of trust or authority in relation to the victim, as an aggravating factor for sentencing purposes. Canada's Criminal Code (s 718.2) is a case in point.

Another area of legislative intervention in the elder abuse field involves mandatory or permissive reporting laws. For example, in Canada, a number of provinces have laws that require community care facility staff to notify relevant authorities if they witness or become aware of an older adult who is residing in a long-term care home being abused or neglected,24 while some provinces have mandatory notification procedures in relation to older adults living anywhere in the community.25 In a similar vein, the recently enacted Social Services and Well-being (Wales) Act 2014, which will come into force in April 2016, imposes a duty on health services staff to report suspected neglect or abuse of an adult who "has needs for care and support" to a local authority (ss 126, 127).

Some jurisdictions have also enacted laws providing for the reporting of suspected financial abuse (sometimes referred to as "senior fraud"). For example, the Canadian Government recently introduced amendments to the Personal Information Protection and Electronic Documents Act 2000 to allow banks and other financial institutions to notify officials if they suspect that an elderly client is the victim of financial abuse.26

However, as the WHO (2015) report noted, some countries have introduced specific adult protection laws. A recent example is England's Care Act 2014, which came into effect in April 2015.27 Sections 42-46 of this Act deal with safeguarding adults at risk of abuse and neglect. Together with Schedule 2 of the Act and accompanying statutory guidance (Department of Health [DOH], 2014, chapter 14), these provisions create a legal framework to guide a range of relevant organisations and individuals with responsibilities for older adults. In particular, the Care Act requires local authorities, which also have statutory responsibility for child protection, to make "whatever enquiries it thinks necessary" when notified of suspected abuse or neglect of an adult with care and support needs in their area, with a view to determining what, if any, action may be needed (s 42). The statutory guidance makes it clear that these provisions are intended to cover a wide range of abuse and neglect, including domestic violence, physical and sexual abuse, psychological harm, financial abuse, organisational abuse (poor care practices within an institution) and self-neglect (DOH, 2014, paras 14.16-14.26).

8.2 Adult protective services

The WHO (2014) report noted that the countries furthest along in efforts to protect and support older adults include dedicated adult protective services as part of their national policy. However, it also reported that in terms of responses to elder abuse, implementing adult protective services was the least commonly reported initiative, with only a third of respondent countries indicating they had such services in place.

The elder abuse literature suggests that the United States is generally regarded as having the most longstanding and fully developed system for reporting and treating cases of elder abuse (WHO, 2014). Central to this system are state-based adult protective services, which employ dedicated adult protection workers to investigate and prosecute substantiated allegations of elder abuse. Like child protection agencies, adult protective services in many US states are supported by mandatory reporting laws,28 while others have developed specialist risk assessment tools, such as the Elder Abuse Suspicion Index, to screen for elder abuse (Hoover & Polson, 2014). Some states also have elder fatality review teams, convened by a coroner or medical examiner, to identify and examine systemic issues raised by these cases (Stiegel, 2005).

Adult protective services agencies in the Unites States are supported by the National Adult Protective Services Association (NAPSA), a not-for-profit organisation established in 1989 to provide program administrators and their staff with a forum for sharing information and professional development.29 NAPSA also conducts national research on issues relating to the delivery of adult protective services, provides training and technical assistance to adult protective services professionals, and provides information to the public on issues relating to elder and vulnerable adult abuse, exploitation and neglect.

As noted above, England has recently added investigations of elder abuse to the range of statutory responsibilities of local authorities, which currently investigate referrals of suspected child abuse and neglect.30 The Care Act 2014, which came into effect in April 2015, provides that where a local authority has reasonable cause to suspect that an adult in its area has needs for care and support, is experiencing or is at risk of abuse or neglect, and is unable to protect himself or herself against the abuse or neglect or the risk of it, the local authority must make (or cause to be made) "whatever enquiries it thinks necessary to enable it to establish whether any action needs to be taken to prevent or stop the abuse or neglect" (s 42). Abuse and neglect for this purpose cover a wide range of behaviours, including misusing medication, using physical restraints, misappropriating property or benefits, providing poor care practice in a hospital or aged care facility, and withholding nutrition or heating (DOH, 2014, para. 14.17). It also includes self-neglect, such as neglecting one's personal hygiene or health. The legislation is supported by statutory Care Act guidance for relevant professionals and organisations. At present this does not include a framework for risk assessment but it does provide a list of "potential indicators" of abuse, including financial abuse (DOH, 2014, para. 14.23).

As noted, a local authority is not obliged to investigate a notification itself if it decides that others are better placed to conduct the enquiry (Care Act 2014, s 42; DOH, 2014, para. 14.84). For example, where the alleged abuse involves poor care practice within a care home, an employer-led investigation may be more appropriate (DOH, 2014, para. 14.33). The Care Act guidance (DOH, 2014) suggests that in many cases a professional such as a social worker, housing support worker or GP who already knows the adult will be the best person to conduct the enquiry (para. 14.84). Where a crime is suspected (such as sexual assault, fraud, or unlawful imprisonment), the matter should be referred to the police to lead the investigation with the local authority's support (para. 14.85). However, the local authority retains overall responsibility for ensuring the enquiry is acted upon and must assure itself that the investigation satisfies its duty under the Care Act to decide what action (if any) is necessary to protect the adult, and that such action is taken. The local authority also has a responsibility to challenge the agency making the enquiry if it considers the process or outcome is unsatisfactory (para. 14.84).

The English model does not prescribe any particular form of investigation, allowing a flexible approach that accommodates the person's circumstances (DOH, 2014). For example, the enquiry itself could range from a conversation with the affected adult or, if they lack capacity or have substantial difficulty in understanding the enquiry, with his or her representative or advocate, through to a more formal multi-agency course of action (para. 14.64). The Care Act guidance provides that the process should be "person-led and outcome-focused", ensuring the affected adult is involved in the decision about how best to respond to the safeguarding situation, with a decision that reflects the adult's wishes wherever possible (para. 14.15). More particularly, the guidance provides that the affected adult "should experience the safeguarding process as empowering and supportive" (para. 14.79).

Safeguarding enquiries may result in a range of outcomes (DOH, 2014). The investigation might lead to a review of the existing care plan, to disciplinary action, and/or to prosecution if the abuse or neglect is substantiated (para. 14.89). The guidance provides that the outcome should be proportionate to the level of concern, with priority given to ensuring the person's safety and wellbeing (paras 14.66, 14.78). The local authority must also ensure that any action taken that restricts the person's rights or freedoms is the "least restrictive necessary" in the circumstances (para. 1.14).

In a similar fashion to child protection investigations, the Care Act requires the convening of Safeguarding Adults Reviews (SARs) whenever an adult in the local authority's area dies as a result of abuse or neglect and there is concern that the local authority or a partner agency (such as a health service or the police) could have worked more effectively to protect the adult (s 44). The aim of the SAR is to "promote effective learning and improvement action to prevent future deaths or serious harm occurring again" by identifying what the relevant agencies and individuals in the case might have done differently that could have prevented harm (DOH, 2014, para. 14.135, 14.139).

In contrast to England and the US, specialist responses to suspected elder abuse in some other countries are located within the primary health care sector. Ireland, for example, has a dedicated Elder Abuse Service (EAS) located within the Health Service Executive (HSE) to investigate allegations of elder abuse (O'Donnell et al., 2012). The EAS was established in 2007 to provide a coordinated community-based approach to elder abuse. This model centres on a National Elder Abuse Steering Group, which oversees the provision of HSE services for older adults, and designs and delivers elder abuse training for health services staff and the voluntary sector (HSE Elder Abuse Services, 2013). In practice, investigations are conducted by qualified social workers, known as Senior Case Workers, who are based within primary community care services. Senior Case Workers follow up suspected cases of abuse involving people aged 65 and over that are notified to the HSE through its dedicated HSE Information Line (which allows victims and people who are concerned about elder abuse to make a complaint). The Senior Case Worker's investigatory role includes working with the older person and their family and carers to resolve the concerns, and develop a plan that will support the person's safety and care needs (HSE Elder Abuse Services, 2013; O'Donnell et al., 2012). In doing so, the Senior Case Worker's response is guided by a presumption that the older person has mental capacity and a right to self-determination (HSE Elder Abuse Services, 2013).

A more recent international approach to adult protection is one that situates the issue of elder abuse within a broader family violence framework. This is the model used in New Zealand. New Zealand has an Office for Senior Citizens, established in 1990, and a Minister for Senior Citizens. However, responsibility for adult protective services is located within the Department of Family and Community Services, which has responsibility for delivering the country's range of family violence prevention programs. This includes funding for 24 specialist elder abuse and neglect prevention services across the country. Age Concern, a long-standing charitable organisation (founded in the 1940s) dedicated to people over the age of 65, delivers 19 of New Zealand's 24 specialist elder abuse and neglect prevention services.31 The New Zealand Government also contracts Age Concern to provide national training on elder abuse to professionals in the family violence, primary health and aged care sectors.

8.3 Multidisciplinary and multi-agency responses

As the discussion above indicates, the prevention of elder abuse affects a range of different areas of government responsibility. A report published by the National Centre for the Protection of Older People in Ireland, for example, noted the "ongoing debate as to whether it is primarily an issue of human rights, domestic violence, public health, adult protection, criminal justice or empowerment" (O'Donnell et al., 2012, p. 3). In fact, a key theme in the international literature concerns the multi-faceted nature of the issue, and the associated need for multidisciplinary and multi-agency responses. However, a recent US report noted that while there is broad agreement that elder abuse requires a multisystem response, such efforts are often poorly coordinated (Connolly, Brandil, & Breckman, 2014, p. 24).

This recognition has led to growing efforts to develop coordinated responses across the key organisations that provide services for older adults. For example, in June 2015 the New Zealand Minister for Senior Citizens announced a new umbrella initiative called Connects that will see a number of community-based agencies work together to help prevent social isolation and abuse of older adults in that country (Barry, 2015). Similarly, some countries have looked at increasing collaboration and reducing overlaps between the main areas of government responsibility for senior citizens. For example, a 2013 report by the US Government Accountability Office (GAO) identified leadership and coordination as being critical to ensuring the efficient use of limited government resources in the elder justice area (US GAO, 2013). In particular, the report recommended that the Department of Health and Human Services and the Department of Justice (which at that time separately administered 12 overlapping programs affecting elder justice) work to identify common objectives and outcomes and develop a coordinated elder justice approach, including a national public awareness campaign.

A concern to encourage collaboration and multi-agency responses also underpinned the passage of the Care Act 2014 in England, described in the previous section. The adult safeguarding provisions of this legislation grew out of a 2011 Law Commission report, which recommended the creation of a partnership approach to the issue of elder abuse, with local authorities having lead coordinating responsibility. To this end, the Care Act requires every local authority to set up a multi-agency Safeguarding Adults Board (SAB) in their local area. The legislation provides that membership of an SAB must include the local authority, the chief officer of police and a local representative of the National Health Service. The inclusion of the police recognises the critical role they play in investigating crimes and bringing perpetrators to justice where an older adult has been abused. The statutory guidance also encourages local authorities to invite other relevant agencies (such as housing providers, carer groups, general practitioners, and ambulance and fire services) to be a member of the SAB to the extent needed to effectively carry out the SAB's duties (Care Act, Schedule 2; DOH, 2014, paras 14.117-14.118).

The purpose of establishing SABs is to facilitate a "timely and effective" coordinated response by all relevant agencies work to the abuse and neglect of older adults (DOH, 2014, para. 14.7). Early sharing of information is central to this, and the Care Act supports this aim through a statutory information-sharing requirement: an organisation or individual who is likely to have information of relevance to the SAB's functions must share it with the SAB when requested to do so (s 45(1)). The Care Act also requires all organisations involved to have arrangements in place that clearly set out the process for sharing information between each other (s 6). In addition, local authorities and their partner agencies are required to collaborate with each other, to have clear protocols of understanding about how they will share information with one another, and to have mechanisms in place to enable early identification and assessment of risk (DOH, 2014, paras 14.108 & 14.53-14.55).

Each of the three core partners of the SAB (the local authority, the police and the health service) is required to make a resource contribution to ensure the SAB can carry out its functions and oversight role (DOH, 2014, para. 14.105). The Care Act also requires the SAB to publish:

  • a strategic plan for each financial year that sets out how it will meet its main objective (to help and protect older adults in its area), and what each member is to do to implement that strategy; and
  • an annual report detailing what the SAB has done during the year to achieve its objective, and what it and each member has done to implement its strategy (Care Act, s 44 & Schedule 2).

In addition to these obligations, the Care Act requires SABs to conduct a Safeguarding Adults Reviews (SAR) whenever "there is reasonable cause for concern about how the SAB, members of it or others worked together" to safeguard an older adult and "death or serious harm arose from actual or suspected abuse" (s 44(1)). The purpose of these reviews is to learn lessons and improve practice and interagency working. Agencies are expected to cooperate with the review, and the Care Act also gives SABs the power to require organisations and individuals to provide relevant information.

8.4 Awareness-raising campaigns and public education strategies

The WHO (2014) Global Status Report on Violence Prevention noted that in most cases where laws have led to a change in attitudes and behaviours, the enactment of legislation has been accompanied by widespread awareness-raising initiatives and public education campaigns, as well as capacity building for relevant professionals. However, while cultural norm-change strategies were a commonly reported approach to address violence against women, only 23% of countries had reported implementing public information campaigns on elder abuse.

One country with a long history of using national awareness-raising campaigns in relation to elder abuse is Ireland. Since 2004, Ireland has run a "Say No to Ageism Week" public awareness campaign about discrimination against older adults each year, using advertising, social media and radio to showcase older employees and emphasise the benefits of inclusiveness (WHO, 2015). Awareness raising is also one the Canadian Government's keys strategies for preventing elder abuse. One aspect of this strategy is the New Horizons for Seniors Program (NHSP), which funds community organisations across Canada for projects that focus on elder abuse awareness. Each year, the NHSP invites organisations to apply for funding for community-based projects that will empower older adults to share their knowledge, skills and experiences and to address social isolation among seniors (Employment and Social Development Canada, 2015). The Canadian Government also developed an advertising campaign, "Elder Abuse - It's Time to Face the Reality", launched in 2009, which airs regularly on television, with print and online components. A 2011 public opinion survey indicated that this campaign had significantly increased awareness of elder abuse among Canadians (Government of Canada, 2014).

The WHO has also instituted an Instagram campaign with the hashtag #YearsAhead to combat ageism. It is designed to convey the idea of expenditure on older populations being an investment, rather than a cost, that can yield significant dividends, both for the health and wellbeing of older people and for society as a whole, through increased participation, consumption, and social cohesion.

Around 26% of countries worldwide reportedly have implemented education campaigns to address elder abuse (WHO, 2014). Many of these involve the provision of online information aimed at assisting older adults to navigate financial issues and understand their legal rights, while others provide advice and links to support services for carers who have responsibilities for an older person.

The United States, for example, has an Office of Financial Protection for Older Americans within its national Consumer Financial Protection Bureau, whose website offers services along these lines.32 The New Zealand Government, which has a Minister for Senior Citizens, has also recently established a new SuperSeniors website,33 which provides information and advice about financial management, entitlements to social security benefits, and enduring powers of attorney, along with online support and information programs for carers (Barry, 2015). The Canadian government provides a similar website,34 which has information for older adults, including links to resources on fraud prevention and how to improve financial literacy,35 links to a Senior's Abuse Support Line in each Province,36 and an information portal for caregivers covering topics such as self care,37 and the legal obligations of employers of people with care responsibilities.38

8.5 National action plans

A final initiative that has been adopted by a number of countries is the development of a national action plan. The WHO (2014) emphasised the importance of having comprehensive data-driven national action plans to ensure effective violence prevention. However, it noted that while many of the surveyed countries reported having national action plans for child maltreatment (71%) and intimate partner violence (68%), fewer than half (41%) had addressed elder abuse. The report noted that such plans are an important "way for countries to articulate how violence impacts the health, economic viability and safety and security of a nation", and provides direction for policy makers about what needs to be done, including the identification of objectives, priorities, assigned responsibilities, a timetable and an evaluation mechanism (WHO, 2014, p. 24).

It is worth noting that the WHO is in the process of developing a Global Strategy and Action Plan on Ageing and Health. The public consultation period for this initiative ended on 30 October 2015 and will be considered by the 69th World Health Assembly in May 2016.

20 The WHO (2015) report also noted the importance of providing access to social security benefits for older adults, along with protection from the costs of health care and social care.

21 It contains data collected from 133 countries, representing 88% of the world's population.

22 Note that the Los Angeles District Attorney's Office has a specialist Elder Abuse Unit to prosecute elder abuse offences.

23 California Penal Code § 368(b)(1). These offences are punishable by a fine not exceeding US$6,000, or by both that fine and imprisonment, or by imprisonment in the state prison for two, three or four years.

24 See for example, the British Columbia Community Care and Assisted Living Act 2002, c 75, and the Ontario Long-Term Care Homes Act 2007, c 8.

25 Adult Protection Act, RS, Nova Scotia, c 2.

26 The amendments were enacted by the Digital Privacy Act, which received royal assent on 18 June 2015.

27 The passage of the Care Act places on a statutory footing the duties imposed on local authorities by Article 5 of the European Convention on Human Rights to intervene where adult abuse is suspected (see A Local Authority v A [2010] EWHC 978 (Fam), per Munby J). Similar legislative changes were enacted in Wales. See Part 7 of the Social Services and Well-being (Wales) Act 2014, which will come into force in April 2016.

28 There are some exceptions (such as New York) that have resisted this out of concerns about the civil liberties of older adults (see Brownell, 2010, pp. 1-15).

29 See the NAPSA website: <www.napsa-now.org>.

30 See the National Society for the Prevention of Cruelty to Children, Child protection in England: Referrals and investigation web page: <www.nspcc.org.uk/preventing-abuse/child-protection-system/england/referrals-investigations>.

31 See contact details at Age Concern: <www.ageconcern.org.nz/ACNZPublic/Local_Age_Concerns/ACNZ_Public/AroundNZ.aspx?hkey=189abbc5-0199-4204-b7f6-582dc8804305>.

32 See Financial Protection for Older Americans web page: <www.consumerfinance.gov/older-americans>.

33 See the SuperSeniors website: <superseniors.msd.govt.nz>.

34 See the Government of Canada Seniors website: <seniors.gc.ca>.

35 See Banks and Financial Literacy we page: <yourmoney.cba.ca/seniors/banks_financial_literacy>.

36 See Senior's Abuse Support Line website: <www.seniorsabusesupport.ca>.

37 See Self-Care for Caregivers web page: <www.phac-aspc.gc.ca/publicat/oes-bsu-02/caregvr-eng.php>.

38 See Canadian Employers for Caregivers Plan web page: <www.esdc.gc.ca/eng/seniors/cecp/index.shtml>.