Abuse and Neglect of Older People
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This article is the third of three articles which examine family violence and abuse. This issue has been identified as a priority issue by the National Council for the International Year of the Family. Here the author looks at elder abuse. The article covers definitions of the forms of elder abuse including psychological abuse, economic abuse, physical abuse and neglect, the incidence of abuse, legislation, detection, intervention and prevention. She explains that abuse is more likely to occur 'first, as the relations between the older person and the carer become more intimate and, secondly, as the older person's daily needs begin to significantly distort a carer's time schedule and personal space requirements'.
Australia is experiencing rapid population ageing. This is a result of a decline in both birth levels and mortality levels as well as an increase in post-war migration. As a percentage of the total population, the number of people aged 65 and over is projected to increase from 10.7 per cent in 1991 to about 12 per cent in 2001. By next century the change will be more marked when increases will rise to between 16 and 18 per cent in 2021, and then to between 19 and 21 per cent in 2031 (ABS 1988).
The aged population is diverse. It encompasses different groups, such as older women (in the year 2001 women over 80 will outnumber men by more than two to one), the rural elderly, the ethnic elderly, the Aboriginal aged, the disabled aged and frail aged. Socio-economic status is also important. Many of Australia's older people live in poverty or near-poverty (ABS 1991).
There are therefore important questions to be considered. How is Australian society coping with an ageing population? Has government incorporated the heterogeneity of older people in its policy measures? Does legislation deal specifically with matters concerning older people? This paper will address these questions in terms of the fact that older relatives in some sections of Australian society are considered to be a burden to the family. The consequence of this can lead to abuse.
Defining the Problem
There have been many different types of abuse described under the general term 'abuse of older people' or 'elder abuse'. It can, however, be specifically defined as a 'pattern of behaviour by a person that results in physical or psychological harm to an older person', (McCallum, Matiasz and Graycar 1990). When referring to elder abuse, two broad types are distinguished: abuse and neglect. Abuse is commonly an act of commission, there is an active involvement or interaction on the part of the abuser. Neglect, by comparison, is used as a general label for acts of omission, namely those with only a passive involvement of the abuser (McCallum, Matiasz and Graycar 1990).
The abuse of older people can, in turn, take several different forms. These are: psychological abuse, economic abuse, physical abuse and neglect, broad definitions of which are outlined below.
Psychological abuse is the infliction of mental anguish. It includes actions which cause fear of violence, isolation or deprivation, feelings of shame, indignity and powerlessness. These actions include sexual harassment, name-calling and other forms of verbal assault, such as repeated threats and insults. It also includes actions that demean the older person, such as restriction of access to appropriate clothing, toileting or bathing, as well as actions that cause emotional distress by depriving older persons of the normal comforts of human existence, such as access to friendships and personal relationships, access to people who speak their own language, access to privacy and the right to be treated with respect. Denial of caring attention or even access to grandchildren and friends unless they consent to signing over assets to an adult child are also aspects of 'elder abuse'.
Economic abuse is the illegal or improper use of an older person's money, property or other assets by someone other than the owner. Examples of economic abuse include misappropriation of money, valuables or property, forced changes to a will or other legal documents and denial of the right of access to, or control over, personal finances. Physical abuse is the non-accidental use of physical force or coercion to inflict bodily harm. It includes assault, restricting of freedom, and sexual abuse.
Neglect consists of the deprivation by a carer of basic necessities, such as food, liquids, or medication, or services, especially services that are necessary for maintaining physical or mental health. Neglect may be active or passive. This distinction is needed to avoid some of the potential confusion between abuse and neglect.
When considering the maltreatment of older people (most often referred to as 'elder abuse') it is important to focus on their living arrangements. About 95 per cent of older Australians live in private homes where accommodation arrangements vary. Some individuals either live alone or with a spouse; some share with siblings or other relatives; some share with friends of their own generation; and some live with single or married offspring who themselves may have children or grandchildren (McCallum, Matiasz and Graycar 1990). The remaining 5 per cent live in specialised aged-care accommodation. This is contrary to the widespread belief that a high proportion of older people live in 'homes'.
From both Australian and overseas studies, it has generally been estimated that around 3 per cent of people aged 65 years and over have suffered some type of abuse (McCallum 1994). A recent study at Hornsby Ku-ring-gai Hospital, however, raises this figure to 4.6 per cent (Sadler 1994), while the NSW Task Force on Abuse of Older People (March 1992) revealed that as many as 5 per cent of the over 65 age group become victims of abuse. A further 8 per cent of adults know an older person who has been abused (McCallum et al 1990).
Pillemer and Finkelhor (1988) discovered that older people in poor health are three to four times more likely to be abused than those in good health, and that maltreatment cuts across economic, social, religious and educational lines. They also found that the rates of abuse were no higher for people 75 and over than for those 64 to 75 years old. Kosberg (1988), on the other hand, describes the high risk groups as: female, very old, dependent, drinkers, in poor relationships, self-blaming, excessively loyal, stoic and isolated. Anderson and Thobaben (1984) in their analyses of conditions characterising abuse, highlighted the pathological nature of the carer, the stress of caring for an often impaired older person, the very close relationship between the carer and the elderly person when the dependency of one may be the trigger for the other, and the intergenerational transmission of violence.
Dependency appears to be the common denominator. Wolf, Godkin and Pillemer (1984) outline two conflicting hypotheses about dependency. The first is that the greater dependency of older persons leads to stress on the carer/relatives, which may manifest in violence. The second hypothesis focuses on the stressed carer. The dependency of the abusive relative upon the elderly person is the crucial factor in maltreatment. Perpetrators, because of their own dependency, react to the stress caused by the dependent person's impaired social functioning, caused, for example, by emotional problems, Alzheimer's disease, or brain damage.
Abuse is therefore more likely to occur, first, as the relations between the older person and the carer become more intimate and, secondly, as the older person's daily needs begin to significantly distort a carer's time schedule and personal space requirements (Galbraith and Zworkowski 1984). Stress levels, already pushed to the limit, can be severely tested when an extra variable is introduced into the family unit.
At the present time, there is no Australian legislation which protects older people from abuse and neglect in the home. Intervention strategies to detect and prevent elder abuse need to be introduced. In order to ensure a consistent approach to the identification of data on abuse as well as maximum cooperation in the detection of, and intervention in, abuse situations it is important that a universal definition be adopted by government departments, the police, health professionals and service providers. This definition should be used as a guideline for identifying unacceptable behaviour by any person in a caring, kinship or friendship relationship with an older person. Universal guidelines would develop from a universal definition. By adopting a common approach, all agencies and individuals would be aware of the potential contribution of others, not only in detection and intervention, but also in the prevention of elder abuse.
To obtain maximum cooperation and optimum delivery of services in regard to elder abuse, strategies need to be developed initially at Commonwealth Government level. State and territory governments then need to adopt proposals to complement a national strategy. Local government could further refine its policies for older residents based upon the principles of the national and relevant state strategy. This technique could help to ensure that older people across Australia are accorded a uniform level of service opportunity, while at the same time allowing local governments to have a national and state focus which they can adapt to meet their local community requirements.
The effectiveness of any intervention strategy is ultimately dependent upon the ability to recognise cases of elder maltreatment. However, the detection of such cases is not easily accomplished. Victims of elder abuse and neglect are often incapable, either physically or psychologically, of stopping the abuse. Fear of further punishment or abandonment keeps others quiet, as does the shame and guilt associated with the fact that the abuser is often a close family member. Moreover, the person in the caregiver's role, who normally would be most likely to identify and seek assistance for physical or emotional problems, has a strong vested interest in keeping such problems hidden.
Although many professionals may be well-positioned to detect any maltreatment of older people, they lack the specific training which would allow them to follow through with such cases (Anderson 1981; Kosberg 1988). This is where standardised procedures for the identification and referral of individual circumstances would facilitate cooperation and coordination between agencies such as community care workers, geriatric and rehabilitation services, hospitals, medical practitioners, solicitors and chamber magistrates. Through such a variety of agencies, it becomes possible to detect the more subtle forms of abuse (emotional, psychological and economic) as well as the more obvious cases of physical abuse.
A particularly contentious aspect of the detection issue concerns the appropriateness of mandatory reporting. No state or territory in Australia has laws which enforce mandatory reporting of elder abuse. Such mandatory reporting could be counter-productive in that it could further disempower older people and perhaps result in their being placed in an aged-care institution.
Once cases of elder abuse have been identified, the next step is intervention. Intervention strategies can involve a wide range of services including legislative and law enforcement agencies, education and counselling, health and financial services, emotional and physical support, family and respite care, advocacy and guardianship (The Office of the Public Advocate, Victoria 1990). Two of these services, the police and counselling, are particularly relevant. And, of course, counselling leads to the introduction of other services.
The police are often called on when abuse is detected in a domestic situation. In the role of law enforcement they have powers to protect the victim from any dangers and where appropriate to refer them to other agencies. In cases of fraud, the role of the police can also be one of apprehension. They could also raise public awareness about abuse of older people and its unacceptability (New South Wales Task Force on Abuse of Older People 1992).
Counselling and associated support services can take several different forms. For instance, it could be family counselling which would involve all family members and not just the victim or the perpetrator of the maltreatment. This approach proceeds from the assumption that all family members may be affected by, and contribute to, the environment within which abuse occurs (Edinberg 1986). Treatment strategies may also focus more specifically either upon the abuser or on the abused. In the former case, alcohol or drug treatment programs may be accessed in order to help the abuser cope with problems of substance dependency. Intervention strategies on behalf of the victim may focus on the attempt to provide reassurance and to help the older person cope with the consequences of maltreatment. He or she may need assistance in dealing with the self-blame that frequently accompanies abuse and in resolving any emotional difficulties which maltreatment by an intimate may create (Fattah and Sacco 1989). A particularly valuable strategy in this respect could be the use of self-help groups.
However, it is also important to take into account the intergenerational conflict that leads to elder abuse, as well as the fact that the behaviour could be attributed to spouse abuse and may have been a symptom of the relationship for many years. Also, if maltreatment occurs because caregivers are unaware of, or misinformed of the psychological, social and behavioural correlates of ageing, intensive counselling may correct these misperceptions and teach skills that facilitate coping responses (Steinmetz and Amsden 1983; Hooyman et al 1982). In regard to financial abuse, protective intervention can be achieved by transferring control of financial resources to either guardianship or trusteeship arrangements (Task Force on Abuse of Older People 1982).
Any form of intervention must where possible, however, allow older people to remain in charge of their own lives, with the power to decide whether or not they want services, and without the threat of involuntary placement in an aged- care institution.
Prevention rather than treatment is obviously the preferable option. As such, the emphasis changes from examining specific cases in which maltreatment is known or suspected to have occurred, to a concern with older people and their caregivers.
While recognising that the role of caregiver is an extremely valuable resource, it cannot be assumed that all family members are equally suited to provide care for an older person. By the same token, many people do not want to look after their older relatives. Indeed, there is strong empirical evidence to suggest that the abuse and neglect of older people may result from the fact that the caregiver is not economically, physically or psychologically prepared to take on the responsibilities that such a commitment implies (Fattah and Sacco 1989). This would indicate that those individuals and families who are thinking about taking on the caregiving role need to be assessed with respect to their relevant capabilities before such a responsibility is considered (Kosberg 1985). In addition, consideration could also be given to educating people in the techniques required for a caregiving role, as well as awareness training of the expected stresses and where to go if help is required. If the decision to become a caregiver is made, respite programs could alleviate some of the emotional and physical burden associated with the long term provision of care (Anetzberger 1987).
Perhaps, there should also be a recognition that our society is not really equipped to cope with full time care- giving. There is a need to develop non-institutional community alternatives. According to Kosberg (1985), such alternatives might include: 'social settings which meet the needs of the elderly such as public housing for the elderly, foster homes, group homes, etc as well as services that can assist the independence of an older person living in his or her own dwelling. Such community resources include meals-on-wheel programs, home care and chore services, transportation programs, telephone reassurance and friendly visitor programs.'
Problems associated with the high incidence of social isolation among older people also need to be addressed. Increased social integration has the ability to empower the older person and to increase awareness of options regarding his or her circumstances. More active involvement in the community may increase self-confidence and reduce feelings of dependency. It also enhances the visibility of the older person and the caregiver.
It must be emphasised, however, that older people are a crucial resource in Australian society. To date, their potential has been neither acknowledged nor used. There needs to be a significant improvement in the valuation and support of older people. This should emanate from a change in attitudes of older people towards themselves, as well as a recognition by individual families and the general public of their dignity and worth. Old age is beset with negative stereotypes which tend to set older people apart and, in a very real sense create their 'difference'. The result of this can be reduced opportunities for social involvement and independence, especially if the older people themselves come to believe the stereotypes. Older people, with the support of the wider Australian community, should be encouraged to increase their opportunities to remain independent and continue contributing to society.
Finally, the connection between child abuse, spouse abuse and elder abuse needs to be explored thoroughly. Only by establishing links and including these three factors in the incidence of family violence, is it possible to change attitudes and prevent any form of familial abuse from occurring.
- Anderson, (1981), 'Abuse and Neglect Among the Elderly', Journal of Gerontological Nursing, Vol.7, pp.77-85.
- Anderson, L. and Thobaben, M. (1984), 'Checks in crisis: when should the nurse step in?' Journal of Gerontological Nursing, Vol.10, No.12, pp.6-10.
- Australian Bureau of Statistics (1988), Projections of the Populations of Australia, States and Territories 1987 to 2031, Catalogue No.3222.0 Canberra.
- Australian Bureau of Statistics (1991), Census, Canberra.
- Edinberg, M. (1986), 'Developing and integrating family oriented approaches in care of the elderly' in K.A. Pillemer and W.S. Wolf, (eds), Elder Abuse: Conflict in the Family, Auburn Publishing Co, Dover, Mass, pp. 267-282.
- Fattah, E.A. and Sacco, V.F. (1989), Crime and Victimization of the Elderly, Springer-Verlag, New York.
- Galbraith, M.W. and Zworkowski, R.T. (1984), 'Teaching the investigation of elder abuse', Journal of Gerontological Nursing, Vol.10, No.12, pp.2-15.
- Kosberg, J. (1988), 'Preventing elder abuse:identification of high risk factors prior to placement decisions', Gerontologist, Vol.28, No.1, pp.43-50.
- McCallum, J., Matiasz, S. and Graycar, A. (1990), Abuse of the Elderly at Home: The Range of the Problem, National Centre for Epidemiology and Population Health, Canberra.
- McCallum, J. (1994), 'Abuse and neglect of older persons: maximizing orminimizing the problem', in Conference Proceedings 'Crime and Older People', Australian Institute of Criminology, Canberra.
- New South Wales Task Force on Abuse of Older People, March (1992), Abuse of Older People in their Homes, Office on Ageing, Sydney.
- Office of the Public Advocate, Victoria. (1990), No Innocent Bystanders, Melbourne.
- Pillemer, K. and Finkelhor, D. (1988), 'The prevalence of elder abuse, a random sample survey', The Gerontologist, Vol.28, No.1, pp.51-57.
- Sadler, P. (1994), 'Patterns of elder abuse' in Conference Proceedings 'Crime and Older People', Australian Institute of Criminology.
- Wolf, R., Godkin, M. and Pillemer, K. (1984), Elder Abuse and Neglect: Final Report from the Three Model Projects, University of Massachusetts Medical Center, Worcester, MA.
Marianne James is a Senior Research Officer at the Australian Institute of Criminology in Canberra. She is presently employed as the Principal Project Officer for the National Child Protection Clearing House which is located within the Institute of Criminology. The main objectives of the National Clearing House are to collect and disseminate material relevant to the prevention of child abuse and neglect, and to this end Marianne edits a newsletter, Child Abuse Prevention. She has also researched topics concerning the role of older people in Australian society and has written extensively on crime and older people.