This document sets out the approach taken to developing a working definition of abuse of older people to be applied in the Elder Abuse National Research Program. This research program is funded by the Attorney-General's Department. This element has been completed with an additional contribution from the New South Wales Department of Communities. This element of the project has been led by the Australian Institute of Family Studies (AIFS) with support from the National Ageing Research Institute (NARI).

Three strategies supported the development of this working definition: workshops, focus groups and consultations with key stakeholders and lay community members; a literature review; and consideration of the definitions applied in international studies examining the prevalence of the abuse of older people. Together, these strategies supported the development of a working definition that has informed the data collection instruments to be applied in an Australian Prevalence Study.

The development of the working definition and the instruments (Elder Abuse National Research - Strengthening the evidence base - the Foundation for the Australian Prevalence Study) were two separate but related aspects of a three-part research program that has paved the way for the Australian Prevalence Study. The third aspect of the research program was an analysis of Australian Bureau of Statistics (ABS) datasets to examine the extent to which experiences that might be considered 'elder abuse' are represented in those datasets (Hill & Katz, 2019).

Four significant issues have guided the development of the working definition set out in this paper. First, systematic empirical evidence about the abuse of older people in Australia is limited. Consequently, the definition operationalised in research needs to balance precision and exploration.

Second, the professional stakeholder workshops, focus groups and consultations have established that there are both generally accepted and more contentious aspects of the definition, in part influenced by the varied concepts and theories about the abuse of older people. Views vary significantly, with some stakeholders adopting very broad interpretations of the term. However, the third issue - pragmatic concerns in relation to the cost of research and the need to constrain participant burden - means that the working definition needs to support the examination of a set of core issues and concerns that will generate an important empirical evidence base. This evidence can then support further development of definitions for research, policy and practice.

Finally, the definition is based on five key elements: the person who experiences the abuse; the source of the abuse; the acts and omissions that amount to the abuse; the circumstances in which the abuse occurs; and the impact of the abuse. Together, these five elements reflect a multi-dimensional definition amenable to empirical measurement where each of the five elements is present. Two elements of the definition - circumstances and impact - are matters of degree and, to some extent, subjective assessment. Their influence will be better understood at the analytic stage.

This paper synthesises insights from previous research, the literature review and the workshops, focus groups and consultations undertaken for this project. It has five further sections. The next section summarises the method and approach employed to develop the working definition. Section 3 explains the reasons for the adoption of the term 'abuse of older people' rather than 'elder abuse' and discusses the significance of a research definition. Section 4 explains the five elements of the definition and section 5 proposes a working definition. Section 6 examines how questions of working definition have been approached in international prevalence studies. The overall conclusion is presented in section 7.

The stated aim of this project is to 'develop a rigorous definition of elder abuse expressed in plain English, which can be used to design tools to measure elder abuse and inform policy, programme design and awareness-raising activities'.

The empirical and consultative aspect of this project involved workshops, focus groups and consultations across Australia. The design was intended to ensure the views of professionals were captured, as well as some perspectives of diverse groups and communities, namely: Aboriginal and Torres Strait Islander peoples,¹ culturally and linguistically diverse (CALD) groups and lesbian, gay, bisexual and transsexual/transgender and intersex (LGBTI)² people. A summary of the approach is provided here and full details are set out in Appendix A.

Seven workshops were conducted in all state and territories, with the exception of Tasmania. The two and a half hour workshops were attended by professionals from organisations and peak bodies concerned with ageing generally or abuse of older people specifically. Seventy-eight professionals attended the professional stakeholder workshops in total, which were focused on an interactive discussion of the five elements of the definition (see Appendix B for workshop materials). These workshops were conducted in late 2017.

The aim of the focus groups was to collect insights from a diverse range of community members concerned with ageing about elder abuse and how it should be defined. Thirty-five participants took part in four focus groups (including a focus group with older people in Tasmania), with a further seven consultation interviews with individuals who were unable to attend focus groups or workshops at the scheduled times. A particular concern with the focus groups was to ensure that the perspectives of members of diverse groups were covered. For this reason, recruitment particularly targeted groups concerned with LGBTI people and CALD groups. To gain relevant insights to Aboriginal and Torres Strait Islander peoples, consultations included people involved in groups and organisations that represent or provide services to these communities.

In addition to this primary research, the discussion in this paper draws on a literature review of relevant Australian and international sources, including previous work conducted by AIFS (Kaspiew, Carson, & Rhoades, 2016; Qu et al., 2017) and funded by the Attorney-General's Department.

Limitations

The primary data collections conducted for this research involved a limited number of professionals and lay community groups. Consequently, they provide important insights into professional and non-professional views on abuse of older persons and how it should be defined. However, the sample is qualitative and not representative. These insights should therefore be considered exploratory and should not be assumed to be typical or representative of the groups involved in the research.

This section considers the existing definitions of elder abuse applied in Australia; flags some of the underlying theoretical questions; and canvasses the issues that need to considered in developing a definition for research. It also suggests that in Australia, the term 'abuse of older people' is preferable to 'elder abuse'. This point is dealt with first.

Elder abuse or abuse of older people?

Although 'elder abuse' is the locally used and internationally accepted term, unease with the continued application of this term in Australia is evident through this and earlier pieces of research (Qu et al., 2017). The term 'abuse of older people' is used in some organisations and has been adopted in the National Plan to Respond to the Abuse of Older Australians 2019-2023 (Council of Attorneys-General, 2019).

Some participants favoured the continued use of the term 'elder abuse' for its familiarity. However, the following reasons for a shift in language from 'elder abuse' to 'abuse of older people' were also raised in the workshops, focus groups and consultations:

• The term 'elder' has a particular meaning in some communities, especially Aboriginal and Torres Strait Islander communities distinct from a description of a person above a certain age threshold. See, for example, discussion consistent with this point in Lohoar, Butera, and Kennedy, 2014 (see also Australian Government, 2016; Australian Government, 2019).
• 'Older people' captures a continuum of seniority.

In this report, language consistent with the National Plan to Respond to the Abuse of Older Australians is adopted.

Definitions used in Australia

There is no legislative or purpose-built Australian definition of the abuse of older people. Rather, the commonly accepted definition is that adopted by the World Health Organization ([WHO], 2008), which was developed by Action on Elder Abuse UK (AEA UK) in 1995. It reads:

A single or repeated act or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person. (p. 6)

This broadly worded definition provides an 'overarching framework' for the consideration of abuse experienced by older people but it does not illustrate the forms of abuse that may be captured by the definition or the contexts in which they take place (Joosten, Vrantsidis, & Dow, 2017, pp. 9-10).

Another definition applied in Australia is also based on the AEA UK approach, but involves a greater degree of specificity. The Australian Network for the Prevention of Elder Abuse (ANPEA) adopted this definition in 1999:

any act occurring within a relationship where there is an implication of trust, which results in harm to an older person and this abuse may be physical, sexual, financial, psychological, social and/or neglect. (ANPEA, 1999)

The differences between these definitions are subtle: the ANPEA definition includes specific types of abuse, omits distress as a consequence and refers to 'implication' rather than 'expectation' of trust. Significantly, neither of these definitions includes the requirement of 'intention' on the part of the perpetrator of the abuse, unlike the definition adopted by the US Centers for Disease Control and Prevention (Hall, Karch, & Crosby, 2016). It is apparent from this and an earlier study (Qu et al., 2017) that there is a lack of support in Australia for intention to be part of the definition.

There remains a significant distance between the broad formulations in the accepted definitions in Australia and the level of precision required to develop measures for the purpose of assessing prevalence. Further specificity is required in all elements of the definition, but one element raises more complex issues than others. This is: the circumstances in which an expectation or implication of trust arises (see e.g. Bonnie & Wallace, 2003). It is this element that potentially determines whether the abuse of older people as a specific construct is present or not when the other four elements are satisfied. It is also the element least amenable to precise definition.

In this context, it is appropriate to flag some theoretical issues raised in the literature, before setting out the issues raised by each of the five elements.

Conceptual and theoretical approaches

In areas related to complex human problems, theoretical perspectives offer the opportunity to consider how and why such problems arise and how they may be addressed. The academic literature indicates that theories about the abuse of older people have been slow to develop (see e.g. Biggs & Haapala, 2013). Nonetheless, common theoretical perspectives include those based on human rights, socio-ecological perspectives, life-course and feminist perspectives. These theoretical approaches are particularly fitting in considerations of the circumstances in which abuse of older people occurs, and may tend to support wider, rather than narrower, empirical inquiries on this point. They are not mutually exclusive.

A human rights model would suggest that abuse of older people, rather than being exclusively 'located within personal relationships' (Biggs & Haapala, 2013) also arises out of relationships between the state and individuals as a consequence of the way that the state does or does not safeguard the human rights of older people. Locally (Australian Law Reform Commission [ALRC], 2017; Lacey, 2014) and internationally (see e.g. Roberto & Teaster, 2017, p. 28), human rights framings of the abuse of older people are increasingly emerging. In contrast with some other definitions, for example the Council of Europe (2005) Resolution definition of abuse, the definitions applied in Australia do not explicitly endorse a human rights framing. However, they are not necessarily inconsistent with such a framing either.

A socio-ecological perspective also attributes responsibility for abuse of older people to social and community dynamics more widely, based on the idea that these issues influence relationships and behaviours at the individual level (see e.g. Roberto & Teaster, 2017). A life-course perspective is based on the view that vulnerabilities and strengths may be consistent across an individual's life span and that the experience of adversity in later life is linked to adversity in earlier life (see e.g. McDonald & Thomas, 2013). Feminist perspectives draw an analogy between theories of abuse of older people and family violence based on the theory that both of these arise out of and reinforce a power imbalance between the perpetrator and the victim (see e.g. National Clearinghouse on Abuse in Later Life [NCALL], 2011).

As the forthcoming discussion of the five elements of the definition demonstrates, each of these theoretical perspectives are reflected in the approaches that various organisations and individuals apply in Australia.

The literature on the relationship between theory and empirical research acknowledges that they are mutually informing, with theory playing an important role in understanding empirical insights, which, in turn, shed light on the validity or otherwise of theoretical ideas (e.g. Bengtson, Acock, Allen, Dilworth-Anderson, & Klein, 2005, Part 1; Roberto & Teaster, 2017). In this context, research strategies that do not close off the exploration of issues that shed light on theoretical questions - such as the circumstances and relationships in which the abuse of older people occurs - are important. This allows exploration of the relevance of particular theoretical approaches to be examined at the analytic and interpretive research stages.

Approach for research

Given the emergent state of empirical research on abuse of older people in Australia, it is important that research strategies support the testing of theoretical ideas, rather than being based on any particular theoretical position.

Similarly, research strategies need to ensure that approaches are open enough to allow new insights to emerge and be tested and precise enough to yield valid and usable data. In considering the definitions that should be applied in research, as distinct from legislation, policy and practice, a paper developed for the US National Research Council Panel to Review Risk and Prevalence of Elder Abuse and Neglect suggests that research:

should investigate all the conduct and harms that could amount to abuse or neglect … The main point, however, is that the ideal empirical strategy would define the category of interest broadly in terms of conduct and harmful consequences, leaving further narrowing to the analytical and interpretive stages. (Bonnie & Wallace, 2003)

In light of the constraints on research referred to earlier - the most important of which is to reduce participant burden - careful consideration needs to be given to the useability of the definition in data collection instruments. The need for precision in measurement, and the emergent nature of empirical evidence on the abuse of older people, sets research definitions apart from definitions that may be used in legislation, policy and programs. In each of the latter contexts, the rationale for the definition will depend on the purpose of the law, policy or program.

In the context of research, definitions respond to the need for precision in measurement to generate useful and valid data. The next section sets out insights into the issues raised in consultations and the academic literature in relation to the five elements that make up the working definition.

This section examines the five elements of the definition that provided a structure for the fieldwork for this component of the research. As noted, the fieldwork primarily involved workshops with professional stakeholders and focus group discussions with older people and with organisations representing or providing services to CALD and LGBT communities. It also involved a small number of interviews with participants unable to attend the workshops or focus groups and consultations with organisations representing or providing services to Aboriginal people.

In order to develop research measures, it is necessary to clearly identify the issues that the survey questionnaires need to focus on. With this goal in mind, the discussion below will identify areas where there is core agreement (with particular reference to data from the workshops, focus groups and consultations and from the 2017 AIFS Prevalence Scoping Study). In addition to this accepted scope, the discussion will also identify areas where some views are different from, or more extensive than, those generally expressed.

Element 1 (the person who experiences the abuse)

The discussion in this section indicates that the accepted scope of this element of the definition provides that the person who experiences the abuse is an 'older person', with general acceptance of 65 years and above as the relevant age range for identifying older people in the overall Australian population. This accepted scope provides the parameters for the application of this element of the definition for the purposes of the Australian Prevalence Study. The extended scope of this element of the definition relates to the incorporation of the concept of vulnerability with respect to the older person. However, neither this nor specific age criteria have been included as requirements of this element of the definition.

In relation to the use of the term 'older' rather than 'elder', participants in the professional stakeholder workshops and in the focus groups articulated reservations about the use of the term 'elder' in the context of abuse. This was particularly so in relation to its application to Aboriginal and Torres Strait Islander communities. For example, concern regarding the term 'elder abuse' identified cultural sensitivities associated with the use of the term elder in Aboriginal and Torres Strait Islander communities. Participants' concerns were based on the resonance that the term might have in these communities and queried whether it would be appropriately understood by those for whom English was not a first language (see also ALRC, 2017, p. 38).

Of note, however, our consultations with professionals working with older Aboriginal people were not conclusive regarding preferred terminology. The importance of acknowledging the diversity of Aboriginal and Torres Strait Islander communities also emerged in the discussion in this context, and specifically in the Queensland professional stakeholder workshop.

Further in-depth research with older Aboriginal and Torres Strait Islander people would be required to determine the terminology that they would prefer to describe the behaviours of concern to them. In the absence of this research, and given the concerns expressed with the term 'elder abuse', the phrase 'abuse of older people' has been employed in this research.

In relation to the age of the person who experiences the abuse, there is significant support of an age threshold of 65 years. Among the participants in the 2017 AIFS Prevalence Scoping Study, just over one-third indicated that they favoured an age of 65 years in the definition. However, a substantial minority, more than a quarter, did not favour a rigid age criterion (28%), with many open text responses indicating that such criteria are inappropriate, for a range of reasons. Similarly, there were mixed views among participants in the professional stakeholder workshops and the focus groups for the current research regarding whether the definition should include an age limit. Many participants reflected on the arbitrary nature of stipulating an age limit in any definition, and there appeared to be a preference for flexibility on this question of age.

Nevertheless, when reflecting on a potential age specification, participants in the workshops and focus groups generally referenced 65 years as an age at which the definition could apply, with a lower age specification or in the workshops and focus groups lower age range applicable depending on culture, ethnicity and HIV status.

For example, some participants in the professional stakeholder workshops acknowledged that the age of 65 years had been historically associated with access to the age pension, such that it would make sense to adopt this age limit, with the age of 50 years nominated for Aboriginal and Torres Strait Islander populations, given their lower life expectancy as compared to the general population. This observation was also reflected in the consultations with professionals working with Aboriginal communities and aligned with just under half (46%) of the respondents to the 2017 AIFS Elder Abuse Prevalence Scoping Study survey (see also e.g. ALRC 2016; Cotterell, Leonardi, Coward, Thomson, & Walters, 2015).

While participants in the CALD focus group and the focus group with older people referenced the age range of 65 years and over, they also suggested that the relevant age may vary depending on contextual factors, including culture and ethnicity. Similarly, while the discussion in the Western Australian LGBT focus group reflected the general understanding of older person to be a person aged over 65 years, participants reported that gay men living with chronic HIV-related illnesses could be regarded as being old at 57 years of age or earlier.

A further issue relates to whether or not vulnerability should be a requirement for this element of the definition. For some participants in the professional stakeholder workshops, the vulnerability of the older person rather than their age was identified as the key factor. Observations in this regard included that it was not age in isolation that made an older person susceptible to abuse, but also their cognitive and physical capacity or wellbeing and their trust in, and reliance on, other people. While the participants in the CALD focus group supported the use of age thresholds, there were participants who considered that the person who experiences the behaviour would also need to have some form of vulnerability, and that a culturally specific 'vulnerability index' could measure/assess this.

Relevant to these issues, some participants in the 2017 AIFS Elder Abuse Prevalence Scoping Study reflected on the position that age operated as a proxy for vulnerability. However, there was also the acknowledgement of the significant diversity in the age that becomes associated with vulnerability, if this occurs at all. Similarly, reference was made in the 2016 ALRC Discussion Paper to the 'experience of ageing being far from uniform', with the suggested focus on factors such as 'issues of vulnerability, isolation and dependence' (ALRC, 2016, p. 22).

There were, however, a substantial proportion of participants in the workshops and focus groups who expressed concern with the employment of the term vulnerability and who considered it difficult to precisely articulate. Some also raised concern about the risk of victim blaming if the definition was to relate only to vulnerable older people. For some participants, conceptualising this abuse in terms of a power imbalance rather than vulnerability was preferred because it could encompass vulnerabilities, was easier to define and was related to the relationship between the parties rather than focusing on the status of the older person (see further in relation to element 4).

From a measurement perspective, the experiences of people in different age ranges can readily be measured and described separately but measurement of a less objective construct, such as vulnerability, involves greater complexity. The US National Research Council concluded that without further empirical evidence, vulnerability was not amenable to definition (Bonnie & Wallace, 2003). In light of this and other research literature (e.g. see research by Biggs & Lowenstein, 2013, and Goergen & Beaulieu, 2013 as quoted in ALRC 2017, p. 39), and having regard to the contentious nature of the issue as it emerged in the workshop and focus group data, vulnerability has not been included as a requirement of this element of the definition.

In summary, the accepted scope of this element of the definition provides that the person who experiences the abuse is an older person, without specification of a precise age requirement or vulnerability requirement. Nevertheless, the definition will be operationalised in the Australian Prevalence Study having regard to the generally accepted age-based criteria of 65 years and above for older people in the mainstream Australian population. While it is acknowledged that a lower age range may be applicable depending on culture, ethnicity and HIV status, separate research would be required to determine prevalence in these populations as it is anticipated that the representation of some groups, including Aboriginal and Torres Strait Islander people, in the Australian Prevalence Study will be too small to allow for rigorous analysis. The extended scope of this element of the definition relates to the incorporation of the concept of vulnerability with respect to the older person; this has not been included as a requirement. While a definition can provide guidance on this element, rather than articulate strict age limits or selection criteria based on vulnerability, the Australian Prevalence Study survey instruments involving age categories and capturing some data related to vulnerability will nevertheless provide a basis for assessing the extent to which an overlap between age and vulnerability is evident and the conditions in which it occurs.

Element 2 (the act or omission)

The discussion in this section of the relevant act or omission identifies the accepted scope of this element of the definition to include physical abuse, emotional/psychological abuse, financial/economic abuse, sexual abuse, social abuse/isolation and neglect. This accepted scope is captured in this element of the proposed working definition. The extended scope identified by some participants includes issues such as certain restrictive practices, breaches of rights, chemical abuse, technological abuse and systemic issues. Given the necessity to focus the fieldwork for this research and the absence of consensus among participants, this extended scope has not been specifically included in the working definition for the purposes of the Australian Prevalence Study. The fieldwork also reflected limited support for intention to be a requirement of this element of the definition. Further, most participants did not distinguish between what might be identified as severe or less severe behaviour, or reference the frequency of behaviour.

The accepted scope of this element of the definition includes the following acts and omissions as identified by most participants in the professional stakeholder workshops, focus groups and consultations:

• physical abuse (including pushing/shoving, hitting/slapping, punching and kicking)
• emotional/psychological abuse (including verbal abuse such as yelling insults and name calling; intimidation/bullying and harassment; damaging or destroying property; threatening to harm the older person or their family members/friends or pets; threatening to withdraw care and preventing or attempting to prevent access to funds, telecommunication or transport)
• financial/economic abuse (including misuse or theft of finances or other assets and abuse or misuse of powers of attorney)
• sexual abuse (including unwanted sexual contact and rape)
• social abuse (including preventing or attempting to prevent the older person from having contact with family, friends or community - social isolation)
• neglect (including the failure to provide access to essentials such as food and hydration, clean and appropriate shelter, adequate hygiene or medical care).

These well-accepted categories reflect those identified in the data collected for the 2017 AIFS Elder Abuse Prevalence Scoping Study, together with earlier research literature and submissions to the 2017 Australian Law Reform Commission (ALRC) Inquiry (see e.g. ALRC, 2017; Clare, Clare, Blundell, & Clare, 2014; Lindenberg, Westendorp, Kurrle, & Biggs, 2013).

The extended scope of this element of the definition encompasses issues that emerged in the data from participants in the professional stakeholder workshops, focus groups and consultations, as well as from the 2017 AIFS Prevalence Scoping Study (see also e.g. ALRC, 2017). These issues include:

• acts and omissions such as certain restrictive practices not captured in the accepted categories
• breaches of rights including the denial of identity (e.g. gender, sexual, spiritual/religious or cultural)
• misuse of both legal and illicit drugs or other substances (which some labelled chemical abuse)
• technological abuse (including denial of access to technology)
• systemic issues including acts or omissions based on ageist attitudes or on a lack of respect for the older person's human rights, dignity and autonomy/self-determination, or related to the lack of adequate services including health care and housing.

While these issues are outside the accepted scope of this element of the definition, further research could generate insights into the extent to which they occur and their impact on older people, to support further policy thinking and to assess the adequacy of existing frameworks.

More specifically, the lack of access to culturally and linguistically appropriate information and services was a feature of some participant discussion in the CALD focus group and of the consultations with professionals working with Aboriginal communities. Several participants in the 2017 AIFS Elder Abuse Prevalence Scoping Study survey and in the stakeholder consultations also raised concerns about older Aboriginal people, particularly women, in relation to family members who wanted access to their pension money or housing.

Some participants in the professional stakeholder workshops and participants in the LGBT focus group also identified abuse to include societal heteronormativity,³ homonegativity ⁴ and/or transphobia⁵ that resulted in a lack of access to services inclusive of older people's gender/sex/sexuality identity, or that led to lesbian and gay older people living a covert life either in residential care or within their own home. Others raised the issue of the lack of recognition of LGBTI non-biological or non-legal kinships - 'families of choice' - as well as the lack of recognition of wider cultural, linguistic and religious diversity.

In summary, the accepted scope of this element of the definition to be operationalised in the Australian Prevalence Study includes physical abuse, emotional/psychological abuse, financial/economic abuse, sexual abuse, social abuse/isolation and neglect. Intention should not be a requirement of this element as the fieldwork and earlier research reflected limited support for intention to be a requirement of the definition (e.g. Qu et al., 2017). Frequency and severity are not referred to in the proposed working definition. This is because most participants did not distinguish between what might be identified as severe or less severe behaviour, and there was limited engagement by participants in relation to the frequency of behaviour. While not emerging in the consultation process relating to the definition, the issues of frequency and severity have emerged in international prevalence research. As explained below, frequency and severity will therefore be examined in the Australian Prevalence Study and the significance of these factors will be assessed at the analytic stage. While there were identified acts or omissions outside the accepted scope of this element of the definition, as noted above, further research could generate insights into the extent to which these issues occur and their impact on older people.

Element 3 (the perpetrator of the act or omission)

This discussion of the accepted scope of this element of the definition illustrates the wide range of potential perpetrators whose relationship with the older person is characterised by an expectation of trust to be captured in the working definition. The extended scope of this element of the definition includes strangers, organisations and institutions concerned with the delivery of care and services to older people. However, there was an absence of consensus among participants in our professional stakeholder workshops, focus groups and consultations with regard to these potential perpetrators and further research may provide insight into the nature of these interactions. There is also some overlap between the discussion of this element and the fourth element, which captures the circumstances of the abuse (see further element 4).

Key definitions, including the WHO (2008) and ANPEA (1999) approaches outlined in section 3 of this report, do not explicitly refer to an actor or perpetrator of abuse and neglect.⁶ In these definitions the actor/perpetrator is implied in the situational preconditions or circumstances, which in both definitions are an 'expectation of trust' or 'implication of trust' (see discussion of element 4 below).

For research purposes, it is critical to identify the source of the relevant behaviour. Consistent with the WHO and ANPEA definitions, a broad consensus concerning potential perpetrators emerged across both the professional stakeholder workshops and the focus groups in each state and territory. These could include family members, friends, neighbours, professionals and carers whose relationship with the older person gave rise to an expectation of trust. Most participants distinguished in some way between these parties and those who were strangers to the relevant older person.

There were two areas of contention that extended the scope beyond those areas conventionally considered. They involved scammers and organisations and institutions concerned with the delivery of care and services to older people.

In relation to the first area of contention, a number of participants argued that scammers, including those operating through online platforms or as trades or salespeople, should be included in this element. This is because they were identified as operating in way that exploited a power imbalance or vulnerability, often doing so by encouraging an expectation of trust, building a relationship of trust, or by exercising power and control. However, some participants considered that scammers should be excluded from a definition because scamming was covered by other legal avenues.

In relation to the second area of contention, residential care providers, policy makers, governments and other organisations or institutions entrusted with the care of older people were identified by some participants in the professional stakeholder workshops as potential perpetrators. Some participants in the CALD and LGBT focus groups and in the consultations with service providers to Aboriginal communities also identified these organisations or institutions as potential perpetrators.

In summary, the accepted scope of this element of the definition is broad in nature with potential perpetrators ranging from family members and friends through to professionals and carers whose relationship with the older person is such that it gives rise to an expectation of trust. The extended scope of this element of the definition includes strangers (and may include scammers) and organisations and institutions concerned with the delivery of care and services to older people. Further research could shed light on the extent to which older people experience problematic interactions with strangers, organisations and institutions, but it is the accepted scope of this element of the definition that will be operationalised in the Australian Prevalence Study.

Element 4 (the circumstances)

The discussion in this section outlines the accepted scope of this element of the definition as captured in circumstances where there is an expectation of trust arising between the older person and the perpetrator. This element and element 3 are interrelated as both are characterised by this concept of the expectation of trust. The extended scope of this element of the definition includes circumstances where there is a power imbalance between the older person and the perpetrator, and circumstances where there is an absence of a personal relationship, such as circumstances involving strangers or organisations and institutions. Consideration will be given to the views of circumstances extending beyond the conventional formulation of trust relationships. While circumstances where there is a power imbalance will be incorporated in this element of the proposed working definition, research exploring the views of older persons themselves on these questions would assist in resolving whether definitions (for research, policy and practice) should extend to circumstances that do not involve a personal relationship.

Key definitions including the WHO (2008), the ANPEA (1999) and the CDC (Hall et al., 2016) definition referred to in section 3 involve an 'expectation of trust' or 'implication of trust' as characterising the relationships and circumstances in which abuse may occur. In the professional stakeholder workshops and the focus groups, and in the data collected for the 2017 AIFS Elder Abuse Prevalence Scoping Study, it was generally accepted by participants that this trust could arise in a wide range of circumstances and relationships, including those relationships about which there was broad consensus, as referred to above in relation to element 3.

There are, however, three areas where some views extended the trust relationship beyond conventional formulations. These areas were circumstances involving a power imbalance between the parties, circumstances involving organisations and institutions and circumstances that involve scams.

First, as foreshadowed above, there was strong support in professional stakeholder workshops, focus groups and consultations for an approach that accommodated perpetrators of abuse of older people taking advantage of a 'power imbalance'. Some views suggested that the power imbalance had a particular relevance to CALD groups. This was seen to arise from dynamics where an older person was in a position of disadvantage because of their limited English language proficiency and their dependency on others to translate information into their primary language.

Additionally, some participants conceptualised the abuse of older people as an extension of domestic and family violence characterised by the exertion of power and control. For example, participants in one professional stakeholder workshop described abuse of older people as occurring where there was a power imbalance between the perpetrator and victim. Conceptualising this abuse solely as a form of domestic and family violence, however, was not a broadly accepted view in the workshops, focus groups and consultations. The ALRC has also acknowledged that while abuse of older people may be characterised as domestic or family violence, the research in this area suggest greater variability and complexity about the dynamics of abuse of older people in Australia (ALRC, 2017, pp. 40-41).

Second, some participants supported a formulation that did not explicitly exclude organisations and institutions from scope, or even argued that these should explicitly be in scope. For example, policy makers/governments and other organisations or institutions (with particular but not exclusive reference to the aged care system) were identified as potential perpetrators by some participants in the professional stakeholder workshops. This was also reflected in the views expressed by some participants in the focus group with older people, the CALD focus group and the LGBT focus group, as well as participants in the consultations with professionals working with older Aboriginal people. The discussion identified relationships of trust and/or dependence or interdependence or involving a duty of care could emerge with respect to the older person in these circumstances and that, as such, there was scope for the perpetration of abuse to be captured in the definition.

Third, as described in relation to elements 2 and 3, some stakeholders identified that people perpetrating scams should be captured in the definition on the basis that the relationship between the older person and the scammer often involved an imbalance of technological abilities (technological power) such as an understanding of the internet and social media.

In summary, the accepted scope of this element involves circumstances where there is an expectation of trust arising between the older person and the perpetrator. The extended scope of this element relates to circumstances where there is a power imbalance between the older person and the perpetrator and circumstances where there is an absence of a personal relationship. Circumstances where there is a power imbalance will be incorporated into this element of the working definition and operationalised in the Australian Prevalence Study as this is a useful concept to explore empirically, and there was strong support from participants in the fieldwork to do so. Research exploring the views of older persons themselves on these questions would assist in resolving whether definitions (for research, policy and practice) of abuse should encompass situations where the circumstances involve behaviour perpetrated by strangers or by organisations/institutions.

Element 5 (the consequences)

The accepted scope of this element of the definition incorporates a broad understanding of the consequences of harm or distress to the older person. The discussion in this section identifies a multidimensional concept of harm that largely accords with the established definitions (see e.g. WHO, 2008). The discussion will also consider participants' perspectives of the objective and subjective nature of this element, with the working definition accommodating both of these options. The discussion canvasses issues in relation to the timing of the experience and the resulting harm.

Participants in most of the professional stakeholder workshops and the focus groups articulated consequences reflecting a multi-dimensional concept of harm as reflected in the 2017 AIFS Prevalence Scoping Study. These included:

• physical harm (including illness, injury, impairment or death/premature death)
• psychological/emotional harm (including fear and shame)
• financial/economic harm
• social harm (including isolation and the loss of identity and self-determination).

In addition to identifying a broad range of potential forms of harm, there emerged some differences in opinion regarding whether harm (actual or risk of) and distress should be assessed subjectively (from the perspective of the older person) or objectively (from the perspective of a reasonable observer). Data from the 2017 AIFS Elder Abuse Prevalence Scoping Study suggested that distress was considered subjective in nature. Consistent with this, some participants from professional stakeholder workshops observed that this element in the definition should include both real and perceived harm, and result from actions, omissions and/or threats of actions or omissions. This was because regardless of whether harm is real or perceived, it still has an impact on that individual.

Some participants in the professional stakeholder workshops also indicated that the harm should not have to be apparent to, or acknowledged by, the older person, or have to occur at the same time as the act/s or omission/s. There was also hesitation among some participants regarding whether to specify the consequences or impact in the definition of abuse at all. This was because the consequences may be varied and difficult to assess or classify in order to meet a specific requirement. The broad range of consequences was highlighted in particular by participants in the CALD and LGBT focus groups.

For example, participants in the CALD focus group reflected on a range of consequences that may be exacerbated by the unique experiences of CALD older people. Participants described a fear of bringing shame to their family by disclosing the abuse, fear of victim blaming by their CALD community for speaking out, or isolation from friends, communities and services in order to conceal the abuse.

Participants in the LGBT focus group also reflected on a range of consequences that may be particular to LGBTI people, given that they may have frequently faced isolation, anxiety and discrimination. These participants identified that abuse in older age may build on these existing experiences and culminate in more detrimental consequences for the LGBTI older person. Some participants also indicated that the compounding of negative experiences across the life course of an LGBTI older person can reinforce feelings of low self-worth, and lead to the older person normalising the abusive behaviour that they are experiencing.

In summary, the accepted scope of this element of the definition to be operationalised in the Australian Prevalence Study incorporates a broad and multi-dimensional understanding of the consequences of harm or distress to the older person. On balance, it emerged that harm and distress should be captured whether it is assessed subjectively (from the perspective of the older person) or objectively (from the perspective of a reasonable observer), and it should not be required to be apparent to, or acknowledged by, the older person, or for it to occur contemporaneously with the act/s or omission/s. The proposed working definition will leave open both subjective and objective interpretations, consistent with its exploratory nature.

The insights set out in this paper support the adoption of a working definition of abuse of older people that meets two aims. First, to support rigorous data collection on the five core elements through the application of precisely formulated survey questionnaires. Second, to have the capacity to assess some aspects where thinking is not settled to gather empirical evidence that will allow the further development of conceptual and theoretical approaches and policy thinking.

On this basis, having regard to the issues set out in relation to the five elements in the preceding section, the following working definition should inform the development of research approaches:

a single or repeated act or failure to act, including threats, that results in harm or distress to an older person. These occur where there is an expectation of trust and/or where there is a power imbalance between the party responsible and the older person.

In broad terms, this working definition is consistent with the WHO one. It is more precise than the WHO definition in referring to 'failure to act' and specifying that threats amount to abuse. In order to insert an actor into the definition, the term 'party responsible' is included. This compensates for the absence of an actor in the WHO definition.

Conceptually, the working definition extends the WHO definition by the inclusion of a 'power imbalance' relevant to the circumstantial element in addition to an 'expectation of trust', with either or both of these circumstances being required. The justification for this approach is based on the widespread acceptance among Australian stakeholders of the relevance of power imbalances in the circumstances in which abuse of older people occurs. This formulation can cover a range of circumstances referred to in our consultations, including: vulnerability arising from dependence for care, lack of knowledge about the rights of the older person, physical strength, and power over relationships that can be withdrawn (e.g. to create social isolation). The incorporation of power imbalance in the definition to be applied is reflective of recent research in the Australian and international context (see e.g. in the Australian context Bagshaw, Wendt, & Zannettino, 2009; Clare et al., 2014; Joosten, Vrantsidis, & Dow, 2017). This includes research based on the views and experiences of older people, with some participants reflecting on the role played by the imbalance in power and control (Hightower, Smith, & Hightower, 2006; Mysyuk, Gerardus, Westendorp, & Lindenberg, 2016;). The pivotal role played by the concept of power imbalance is also evident in the definitional discussions of organisations including the Elder Abuse Prevention Unit (EAPU, 2019).

Although not specifically articulated in the definition, the acts or omissions to be captured by this definition for the purposes of the Australian Prevalence Study include those within the accepted scope of this element of the definition, namely:

• physical abuse (including pushing/shoving, hitting/slapping, punching and kicking)
• emotional/psychological abuse (including verbal abuse such as yelling insults and name calling; intimidation/bullying and harassment; damaging or destroying property; threatening to harm the older person or their family members/friends or pets; threatening to withdraw care and preventing or attempting to prevent access to funds, telecommunication or transport)
• financial/economic abuse (including misuse or theft of finances or other assets and abuse or misuse of powers of attorney)
• sexual abuse (including unwanted sexual contact and rape)
• social abuse (including preventing or attempting to prevent the older person from having contact with family, friends or community - social isolation)
• neglect (including the failure to provide access to essentials such as food and hydration, clean and appropriate shelter, adequate hygiene or medical care).

Definitional approaches were tested by the research team against scenarios that were raised with the Australian Law Reform Commission's 2017 inquiry. A similar exercise was undertaken at the 5th National Elder Abuse Conference (2018, Sydney) at a session involving approximately 30 conference attendees. The process of testing the definition against scenarios reinforced the extent to which varied views are adopted and applied, even with this working definition.

Summary

In summary, the working definition set out in this section reflects the definitional approach to be applied in further research, particularly an Australian Prevalence Study. The working definition incorporates the five elements of the definition in keeping with broadly accepted approaches. In one area, circumstances, the working definition adopts a broader but still widely accepted approach by referring to a power imbalance as well as an expectation of trust. This will support an empirical approach that will generate insights into some conceptual and theoretical questions relevant to why and how the abuse of older people arises.

Although the development of a working definition supports the implementation of empirical research, including the development of data collection instruments, it does not, of itself, resolve a significant question. This question is where, along a potential continuum of experience from modest to extremely severe, should an experience be considered abuse of an older person where all five elements of the working definition are satisfied? This question raises the issue of whether particular thresholds, particularly in relation to the frequency and severity of acts and omissions and their impact, should be applied in research to generate prevalence estimates. International approaches to this issue are considered in the next section.

This section provides an overview of how definitions were operationalised in selected international prevalence studies. Specifically, it sets out different approaches adopted by the international empirical research in determining the prevalence of elder abuse or the abuse of older people and how thresholds for graduated measures in relation to severity, frequency and impact were applied for each form of abuse measured by the studies (i.e. physical abuse, sexual abuse, psychological abuse, financial abuse and neglect). An approach for setting the thresholds for an Australian Prevalence Study is proposed.

Four international prevalence studies have been reviewed for this paper: UK, 2007 (O'Keeffe et al.); Ireland, 2010 (Naughton et al.); Canada, 2015 (National Initiative for the Care of the Elderly, 2016); and New York, USA, 2011 (Lifespan of Greater Rochester Inc.) (see Table 2). These studies, except the UK study, were all conducted in the last decade and on a large scale. In addition, the four countries are all English-speaking countries.

Approaches to developing thresholds for the abuse of older people

Thresholds (or 'cut-off' points) help us to identify at what point a phenomenon such as the abuse of older people occurs. Thresholds can be developed through a variety of mechanisms that include predetermined approaches, analytic approaches or a mixed approach (i.e. a combination of these). In the context of the abuse of older people, thresholds are developed taking into account the relationship between acts or events (or severity of acts/events), the frequency of particular acts or events, and impact (e.g. whether harm occurs).

• Predetermined approaches draw on existing definitions and existing evidence that indicate at what point harm occurs. Pre-existing approaches may also draw on moral or ethical considerations in determining at what point harm occurs.
• Analytic approaches explore the relationship within data between the frequency of particular events or acts and the respondents' self-reported experience of harm.
• A mixed approach considers both sources of information to develop these thresholds.

Predetermined approaches are useful in that they may reflect community standards about what are harmful or inappropriate behaviours but they may also under- or over-estimate the prevalence of abuse when taking into account reported rates of harm as found in a survey's data. To avoid this over- or under-estimation, a mixed approach is recommended for an Australian Prevalence Study.

The following sections provide some additional detail about how definitions relating to the abuse of older people are operationalised within the four international studies reviewed for this paper and how these studies developed their own thresholds.

Operationalisation of the definitions

Table 1 summarises the definitions and each of five sub-forms of abuse and their operationalisation in the four studies, as well as the estimated prevalence for each sub-form of abuse. The table also includes the definitions developed by WHO (2008; WHO & the International Network for the Prevention of Elder Abuse, 2002). Table 2 shows that the four studies differ in age eligibility, sample size and interview mode. These features (along with the means chosen for establishing thresholds and the number of measures used to measure each form of abuse) also influence the estimated prevalence rates. This means that only limited comparability between these studies and the Australian study is feasible.

Summary of the operationalisation of specific elements of the definitions (see Table 1) in the four studies

Physical abuse and sexual abuse:

• Approach adopted consistently across the studies: one incident would amount to abuse for each of the two forms of abuse.
• Measurement approach is not the same - the number of items for identifying sub-forms of abuse varies across the studies.

Financial abuse:

• Approach adopted consistently across the studies: one incident would amount to abuse for this form of abuse.
• Measurement approach is not the same - the number of items for identifying sub-forms of abuse varies across the studies.

Psychological/emotional abuse and neglect:

• UK and Canada: mainly based on frequency
• Ireland: frequency and impact
• New York: frequency, impact/severity
• Measurement approach is not the same - the number of items for identifying sub-forms of abuse varies across the studies.

Previous examples of developing thresholds

In relation to setting up the thresholds for five broad areas of the abuse of older people, it was not clear from the reports of the four prevalence studies whether the thresholds were set prior to the study, with the exception of the explicit discussion on psychological abuse and neglect in the Canadian study.

For physical and sexual abuse, the thresholds appeared to be guided by the definitions.

Regarding financial abuse, the thresholds appeared to be guided by the definition for the UK, Canada and Ireland. The New York study classified financial abuse based on frequency and impact. It is unclear whether this cut-off was reset during the analytic stage.

For psychological/emotional abuse and neglect, approaches for the development of thresholds appeared to vary. In the Canadian study, the thresholds for psychological/emotional abuse were adjusted in light of the collected data to avoid over-estimates.

While the international studies were generally not explicit about whether the thresholds were set prior to the data collection, the combination of frequency and impact in determining some forms of abuse (e.g. deemed as abuse if 10+ times, or based on impact if less than 10 times) suggests that such thresholds were guided by the definition, but were also likely informed by the analysis to avoid under- or over-estimates.

Note: ^a The international studies (except for the Canadian study) were not explicit about whether thresholds had been established prior to the data collection. The approach listed in this table reflects our assessments of these studies.

This paper has set out the process undertaken for the development of a working definition of abuse of older people for research purposes, specifically the implementation of a national prevalence study.

The process of formulating the working definition involved three strategies: a literature review; a series of workshops, focus groups and consultations; and an assessment of the approaches taken in international prevalence studies. An important consideration in the development of the working definition was the need for it to support the development of research measures and data collection instruments of sufficient precision to support a rigorous prevalence study. For this reason, the working definition has been operationalised based on five core elements.

In broad terms, the working definition is consistent with the WHO definition but is more specific in some areas and is extended in others. The key area of extension is in the addition of the term 'power imbalance' to the term 'expectation of trust' in the context of the circumstances in which abuse of an older person occurs. The rationale for this extension is the significant support for the approach among the stakeholders we consulted.

The working definition will allow insights to be generated that will support the examination of common conceptual and theoretical approaches, particularly a human rights model, a socio-ecological perspective and an approach that posits an imbalance of power as a core element of abuse of older people. Empirical insights to allow these perspectives to be further explored would be available from the implementation of the Survey of Older People and the Survey of the General Community.

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The methodology for developing and building consensus on the working definition involved three main elements:

1. data collection via workshops and individual consultations with professional stakeholders who are involved in organisations or peak bodies concerned with ageing generally or abuse of older people specifically
2. data collection from individuals concerned with ageing/abuse of older people to gain a non-professional perspective (included focus groups and/or consultations with representatives from CALD and LGBTI⁷ communities and with those representing or providing services to members of Aboriginal and Torres Strait Islander communities⁸)
3. consideration of existing evidence and analyses of data to develop thinking about the scope of elements for the definition and to test the exclusionary or inclusionary effects of choices in relation to particular elements.

Sampling strategy

A purposive approach to sampling was employed for this research to facilitate the collection of descriptive and contextual data relevant to the research aims of the study.

Stakeholders from the following groups were invited to participate in the workshops:

• Commonwealth, state and territory government departments and agencies;
• peak bodies, advocacy organisations and service providers for older Australians;
• professional associations and representative bodies, and academics and other stakeholders.

Focus groups were conducted with professionals or individuals who had involvement with older people and with members of the older community. These older people may have had experiences of abuse as an older person themselves or among their family/friends.

In accordance with the stakeholder engagement and communications plan initiated for this research, AIFS and NARI used their professional networks to engage with these groups to promote the project and to recruit participants to the study.

Invitations for the professional workshops across states/territories were sent to nearly 200 professionals from over 100 organisations. In total, 78 professionals attended seven workshops conducted around the country in November and December 2017. There were nine participants in New South Wales, 15 in Victoria,⁹ nine in Queensland, 18 in South Australia, 12 in Western Australia, seven in the ACT, and eight in the Northern Territory.

Invitations for focus groups were sent to approximately 100 individuals. Some participants contacted the research team after hearing about the project themselves or through their connections. Others were nominated by the services or professionals whom they had engaged with or through their personal networks. Four focus groups were attended by 35 individuals. The focus groups in Tasmania and Victoria were attended by a total of 21 people. Seven professionals working with African, Middle Eastern, Eastern and Southern European, and South Asian CALD communities joined the focus group discussion on issues pertinent to people from CALD communities. One focus group was attended by seven professionals working with LGBT clients.

A small number of consultations were conducted with participants who were unable to attend the workshops or focus groups (n = 2) and with service providers to Aboriginal communities (n = 5). These participants were provided with an opportunity to review the Elder Abuse Definition Discussion Paper (see Appendix B) and could elect to participate in the consultation by either face-to-face or telephone interview.

Limitations

More than one-half of the professionals who were invited to attend stakeholder workshops were unable to participate and their views were therefore not reflected in the consultation process or in this report.

Although the researchers used their best endeavours within the project time frame to recruit participants from groups that provided services to, or represented the interests of, Torres Strait Islanders and Intersex people, unfortunately recruitment from these groups was not achieved.

The focus groups involving older people and other individuals from CALD and LGBT communities were attended by those who voluntarily made contact with the research team, or were nominated by the services or professionals with whom they had engaged or via their personal networks.

Participants may have particular views on abuse and mistreatment of older people and these views may not be necessarily representative of the older population, professionals or the general community.

Data collection and analysis

The research design for this project was informed by grounded theory to enable the generation of theory inductively from the data (Charmaz, 2000; Glaser, 1994; Glaser & Strauss, 1967). Rather than testing preconceived hypotheses, exploratory workshop and focus group questions guided the data collection. In addition to considering socio-ecological theory, a human rights-based perspective together with the life-course perspective informed the development of the research. Consideration was also given to feminist theorising as applied in the context of domestic and family violence research.

The workshops and focus groups involved an introduction to the project by the facilitator (an AIFS or NARI researcher) and an overview of the Elder Abuse Definition Discussion Paper. This introduction was followed by an interactive session where participants workshopped elements of the definition. The workshop and focus group guides (see Appendix C) directed the topics covered in these interactive sessions. They were followed by a group discussion to reflect on participants' feedback on the elements examined and to identify points of consensus and divergence among stakeholders.

While it was initially intended that there would also be an opportunity towards the end of the workshop sessions to test the elements using a series of case studies, there was no scope to undertake this in the available time frame allocated for each session. In lieu of this, the proposed definition was tested by the research team via consultation with participants attending the project's National Elder Abuse Conference workshop and via the Elder Abuse National Research Technical Advisory Group.

Data analysis for this project began with a process of open coding to identify primary themes and patterns that emerged consistently within and across the data sources. Theoretical coding was of particular assistance in identifying similarities, differences and connections between these themes and patterns. Selective coding enabled the identification of the core themes - those of highest frequency and of central importance to the definition of abuse of older people emerging from the data (see e.g. Denzin & Lincoln, 2000).

Ethical considerations

The AIFS Human Research Ethics Committee provided ethical review and clearance for this research. While the data collection focused on engagement with professionals, engagement with carers and some older people was anticipated. It was therefore acknowledged that while the focus groups were primarily about definitional issues, participants may reflect on experiences of violence/abuse and on complex family and other relationship dynamics, and they may present with past and/or current risk issues. These circumstances raised significant ethical complexities for the research team, including:

• the need to ensure that data from a potentially vulnerable population who may have experienced significant levels of trauma were collected sensitively, and without causing further trauma
• the need to maintain the anonymity of professional and parent/carer participants and to report data in a way that meant no participant who provided information could be identified.

Several strategies were adopted in order to address these complexities.

First, the research team comprised researchers with substantial experience with legal or social work qualifications and senior researchers with substantial experience in conducting qualitative research of a sensitive nature with vulnerable populations.

Second, following a period of co-presentations at workshops, members of the research team were debriefed as the data collection proceeded. The duty of care protocols that were cleared as part of the ethical clearance process facilitated appropriate responses to distress and enabled referrals to support services where directed. Mandatory reporting obligations were in place in relation to family violence perpetrated in the Northern Territory; however, no reports arising out of this research were required.

Finally, requests were made in participant information material and at the outset of workshops and focus groups for participants to respect the confidentiality of fellow participants. Significant care was also taken to ensure that the data were stored in accordance with the approach outlined in our application for ethical clearance (including electronic material stored on password-protected servers and files and hard copy documents in locked cabinets). The data were also reported in a way that maintained the anonymity of participants.

1. Framework for developing a definition

The Attorney-General's Department has instigated a national research program on abuse of older people in Australia. Phase One of the program includes three interlinked elements:

• the development of a definition to apply in research (Component 1)
• the development of instruments for assessing the prevalence and nature of abuse experienced by older people (Component 2)
• analysis of existing quantitative data sets held by the ABS, and selected administrative data sets to assess existing evidence about the prevalence and natures of abuse experienced by older people (Component 3).

The research program is being led by the Australian Institute of Families, collaborating with the National Ageing Research Institute (NARI) on Component 1, the Social Research Centre (SRC) on Component 2 and the Social Policy Research Centre (SPRC) on Component 3. This document sets out a framework for the methodology to be adopted for Component 1, the development of a definition to be used in research.

2. Background

Component 1 of this project builds on work completed by AIFS in 2017 (Elder Abuse Prevalence Scoping Study) which included consultation on stakeholders' views on common approaches to defining elder abuse. Component 1 extends that work and this document sets out a framework for further consideration of how abuse of older Australians should be defined for the purpose of a national research program. The aim of Component 1 is to 'develop a rigorous definition of elder abuse expressed in plain English, which can be used to design tools to measure elder abuse and inform policy, programme design and awareness raising activities'. The development of a definition is an iterative, empirically informed and inductive process. A research definition will support the development of a knowledge base about the occurrence and consequences of a range of different acts and omissions that may constitute abuse of older people, to support further thinking about policy, practice and legal responses.

Ultimately, the definition to be developed in Component 1 will inform decisions in relation to policy and practice, but initially the core purpose of Component 1 will be to support further research and measurement of elder abuse as a phenomenon in the population. Concern with elder abuse in research, policy and practice has developed incrementally in an inter-disciplinary environment. Issues of definition raise some controversy and elder abuse is theorised in many different ways, with some commentators suggesting it is poorly theorised and lacks coherence (see e.g. Biggs & Haapala, 2013; McDonald & Thomas, 2013).

The definition applied to the phenomenon will determine the types of behaviours and experiences that are and are not measured in research and application of the definition in policy and practice and will determine the nature of the experiences and behaviours that are and are not captured in relevant policy and practice frameworks. Further, the definition will inform community thinking, including among actual and potential victims and perpetrators of elder abuse, about the boundaries of acceptable or abusive behaviours. The formulation of a definition therefore also has important normative consequences.

In the US, where there have been substantial efforts to develop the empirical evidence base and to improve practice and policy, including through statutory means, there have also been concerted efforts to develop rigorous research definitions. In a paper developed for the US National Research Council Panel to Review Risk and Prevalence of Elder Abuse and Neglect, Bonnie and Wallace point to an important strategy that should be applied in research for measurement purposes, as distinct from statutory constructions of behaviour used to determine criminal liability or access to civil frameworks and remedies:

researchers should investigate all the conduct and harms that could amount to abuse or neglect if the perpetrator had the necessary intention or culpability and if other statutory conditions are met. Some subset of this all-encompassing category could be disaggregated in data analysis to represent 'core' cases of abuse or neglect, based on suppositions about the presence of the necessary intention and other conditions. The main point, however, is that the ideal empirical strategy would define the category of interest broadly in terms of conduct and harmful consequences, leaving further narrowing to the analytical and interpretive stages. (Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America, 2003)

In Australia, there are no statutory definitions of elder abuse as there are no specific legal frameworks dealing with this issue (ALRC, 2017). Existing research and analysis, including academic literature and material generated in inquiries such as the Australian Law Reform Commission Inquiry and the Parliamentary Inquiry into Elder Abuse in NSW demonstrate that concerns raised under existing conceptualisations of elder abuse are complex and multi-faceted. They involve acts of commission and omission (e.g. neglect) and broadly encompass psychological abuse, physical abuse, sexual abuse and financial abuse. In each of these areas, there are multiple ways that abusive behaviours can arise. In addition to commonly understood acts, such as physical or emotional abuse, other less commonly thought of manifestations include not meeting medical needs, the misuse of legal and financial instruments and causing social isolation. Further, in different circumstances and among different communities social, economic and cultural issues create dynamics in which particular behaviours may be considered abusive. In relation to Lesbian, Gay, Bisexual, Transgender and Intersex (LGBTI) groups, for example, abuse may arise through exploitation of stigma, secrecy or non-recognition of sexual identity. People and groups from Cultural and Linguistically Diverse backgrounds (CALD) may experience abusive behaviour arising from their particular cultural context. Diverse circumstances are not only seen to give rise to different forms of abuse but they also have influence on help-seeking behaviours and the nature of services required to prevent or respond to elder abuse.

Analyses from the US, point to the importance of applying rigorous and careful approaches to measurement and research so that policy decisions can be made in light of sound empirical evidence (Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America, 2003). The implications of this are twofold. First, an empirical approach that is capable of examining different elements and interactions between them, rather than making a priori assumptions about the significance of particular issues, needs to be adopted. Second, the operationalisation of an empirically informed definition in legislative, policy and practice frameworks may have to proceed on an iterative basis with further definitional decisions being informed by empirical findings.

3. Methodology

The methodology for developing the definition in Component 1 has three main elements:

1.data collections involving focus groups and workshops or one-on-one interviews with professionals who are involved in organisations or peak bodies concerned with ageing generally or elder abuse specifically

2.data collections involving focus groups with individuals concerned with ageing/abuse of older people to gain a non-professional perspective, including focus groups with representatives from CALD and LGBTI communities

3.consideration of existing evidence and analyses of data collected above to develop thinking about the scope of elements of the definition and test the exclusionary or inclusionary effects of choices in relation to particular elements.

The discussion below sets out a framework for the development of the definition, issues to consider in making choices and questions to guide data collections with professionals and individuals.

4. Existing formulations in Australia and stakeholder views

The Elder Abuse Prevalence Scoping Study discussed three commonly used definitions of elder abuse and sought stakeholder views on particular definitional elements that varied among these three formulations. The formulations considered were:

1.A commonly accepted definition of elder abuse is that adopted by the World Health Organization (WHO, 2008), which reflects a public health perspective and was developed by Action on Elder Abuse UK in 1995. This definition identifies elder abuse as:

A single or repeated act or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person [author emphasis] (WHO, 2008, based on the Action on Elder Abuse UK (AEA UK) definition p. 6).

2.A definition also based on the AEA UK definition and adopted by the Australian network for the Prevention of Elder Abuse:

Any act occurring within a relationship where there is an implication of trust, which results in harm to an older person. Abuse may be physical, sexual, financial, psychological, social and/or neglect [author emphasis].¹⁰

3.A more specific definition nominated by the US Center for Disease Control and Prevention (CDC, 2015), provides detailed working definitions of particular categories of elder abuse and includes 'risk of harm' in the definition of elder abuse:

An intentional act or failure to act by a caregiver or another person in a relationship involving an expectation of trust that causes or creates a risk of harm to an older adult (defined as someone aged 60 or older).

3.1 A more explicit human rights focus?

The definitions considered above are broadly similar in nature and position elder abuse as 'located within personal relationships' (Biggs & Haapala, 2013) through their requirements for trust-based relationships. In some countries, formulations in legal, policy or practice instruments have shifted to conceptualisations that explicitly frame abuse-related issues in terms of human rights, although this framing is also implicit in the definitions considered above and explicit in ancillary clauses of the WHO definition. A Council of Europe Resolution (2005), includes a definition of abuse intended to capture all types of abuse, not just elder abuse, in this way:

[A]ny act or failure to act, which results in a breach of vulnerable person's human rights, civil liberties, physical and mental integrity, dignity or general well-being, whether intended or through negligence, including sexual relationships or financial transactions to which the person does not or cannot validly consent, or which are deliberately exploitative.

As Biggs & Haapala (2013) observe, framing of this nature represents a significant shift as, at a macro level, human rights concerns relate to relationships between the state and individuals. In Australia, human rights approaches are increasingly evident in this area (Lacey, 2014) with the Attorney-General's reference to the Australian Law Reform Commission explicitly referring to human rights and human rights instruments (ALRC, 2017). South Australia's policy framework, the Strategy to Safeguard the Rights of Older South Australians 2014-2021 is based on the South Australian Charter of the Rights and Freedoms of Older People, which incorporates principles from human rights instruments that Australian is signatory to (SA Strategy, 2014).

3.2 Stakeholders' views on definitions

Concluding that the stakeholders' consultations and the ALRC Discussion paper supported a definition for national prevalence research that would be 'broad enough to include all manifestations of elder abuse' and be inclusive of a 'wide range of perpetrators', the Elder Abuse Prevalence Scoping Study highlighted some significant divergence in views on key elements of the definition. In summary, the findings indicated that:

• A rigid approach to an age-based element for people who experienced elder abuse is viewed with concern among a significant proportion of stakeholders.
• If harm is to be required to be a consequence of an act considered to be elder abuse, it needs to be broadly defined to capture a range of harms including economic, spiritual and emotional harm.
• Distress as an element of the definition, in addition to harm or on its own, was viewed with concern due to its subjective nature. It was, however, considered as capable of capturing indirect effects of elder abuse.
• Among a majority of stakeholders, intention as an essential element of a research definition was not viewed favourably as it was considered that the definition should be capable of capturing intended and unintended acts or omissions.

The ALRC final report (2017) concluded that:

To obtain a full picture of the abuse of older people, a broad description of elder abuse needs to be used, like the WHO definition. This can serve a range of purposes, including to gain a better understanding of the experiences of older Australians. The information obtained using a wide definition can inform the development of a wide range of policy responses, from community education to criminal offences. (p. 41).

Some respondents to the Elder Abuse Prevalence Scoping Study Survey also called for an explicit human rights-based approach to the development of the definition. For example, one organisation argued that:

The definition of elder abuse must be rights based. The WHO definition, although comprehensive, does not necessarily capture restrictive practices. For instance, keeping an older person with severe cognitive impairment in a locked ward might not cause them harm or distress; keeping a person sedated might not cause them harm or distress; but both are still a denial or autonomy and dignity, and therefore abusive.

This position is not inconsistent with that adopted by the ALRC in relation to restrictive practices. The ALRC discussion supporting recommendations to regulate the use of restrictive practices indicated that such practices will:

in some circumstances be elder abuse. Restrictive practise can deprive people of their liberty and dignity - basic legal and human rights. The practices might also sometimes amount to assault, false imprisonment and other civil and criminal wrongs. (p. 143)

3.4 Elements of a definition and inclusionary or exclusionary effects

The discussion in this section extends the discussion in the Elder Abuse Prevalence Scoping Paper by considering the different elements that may comprise a definition, and their inclusionary or exclusionary effects. The purpose of this discussion is to provide a foundation for the development of a framework that will support the formulation of a definition that can be operationalised in light of two issues:

a.the complexity and variability of the phenomenon

b.the need to ensure that the definition can support measurement approaches that are specific enough to provide rigour but do not compromise the capacity to empirically capture diversity.

3.4.1 Core elements

This discussion identifies five core elements of common formulations of elder abuse and incorporates insights from the survey conducted for the Elder Abuse Prevalence Scoping Study into a discussion on stakeholder views on the scope of each one. Decisions made as to the framing of each element will have inclusionary or exclusionary consequences for the scope of behaviour that is captured, as will the combination of elements that is applied. In this regard, the two elements most likely to result in exclusionary or inclusionary effects are 4 (situational pre-conditions) and 5 (consequences).

Inclusionary approaches in relation to some aspects of the definition - age-related criterion for example - may be counteracted by approaches in relation to other aspects of the definition - such as situational pre-conditions and consequences - that will narrow the scope of behaviour caught by the definition. The discussion also highlights the implications of different choices in relation to elements of the definition in the two issues identified in the preceding section: complexity and variability and measurement.

Element 1: the person who experiences the behaviour

The Elder Abuse Prevalence Scoping Study indicates that there are three main issues for consideration in this element. The first is semantic, arising from concerns in relation to the use of the term 'elder' in common formulations, in the Australian context. This is because 'elder' has a particular meaning in Indigenous communities, and for some other cultures. The SA Strategy refers to abuse of an 'older person'.

A second contentious aspect of this element is age. The WHO and ANPEA definitions both refer to 'older' persons while the CDC definition specifies a person who is aged 60 or older. Different research studies have applied different aged based criteria. Among respondents to the Elder Abuse Prevalence Scoping Study, just over a third indicated they favoured an age point of 65, but more than a quarter also indicated they did not favour a rigid age criterion. Many of the comment responses to the survey in the Elder Abuse Prevalence Scoping Study indicated that such criteria are inappropriate, for a range of reasons. A significant underlying theme in many comments was that age operated as a proxy for vulnerability, and there is significant diversity in the age at which age becomes associated with vulnerability.

This is particularly pertinent for Aboriginal communities, with just under half the respondents to the Elder Abuse Prevalence Scoping Study survey indicating support for younger age categories among Aboriginal and Torres Strait Islander people. Among Aboriginal communities, age-related effects associated with vulnerability are considered to emerge from about 45. For other individuals and groups, there is significant diversity in the extent to which age becomes associated with vulnerability, if this occurs at all. For this reason, some responses suggested distinctions could be based on different age ranges, including 'old' and 'old old'.

Responses to the survey also raised further issues in relation to age, namely the relevance of age differences. Some responses indicated that it should be understood that perpetrators of elder abuse could be older than their victims. Others raised generational differences or age differences that created a power imbalance that weakened the position of the victim.

A third consideration raised in responses to the Elder Abuse Prevalence Scoping Study concerned a need for consistency between an age specified in the definition and the ages applied in different policy frameworks, such as those in relation to aged care and Centrelink benefits.

From a measurement perspective, the experiences of people in different age ranges can readily be measured and described separately. Measurement of a less objective construct, such as vulnerability, involves greater complexity. The US National Research Council concluded that without further empirical evidence, vulnerability was not amenable to definition:

For this reason, the panel regards the meaning of vulnerability as an empirical question - as a referent for the cluster of clinical or psychosocial risk factors associated with increased likelihood of mistreatment. For most research purposes, vulnerability should not be used as a selection criterion; instead, data bearing on vulnerability should be routinely collected and analyzed in most studies of elder mistreatment. (Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America, 2003)

A survey design involving age categories and elements related to vulnerability would provide a basis for assessing the extent to which overlap between age and vulnerability is evident and the conditions in which it occurs. This would support further thinking about the refinement of the definition in specific policy and frameworks.

Questions:

Variability and diversity: do the formulations proposed exclude anyone that should be included according to public policy aims?

Measurement: do the formulations adopted readily translate into measurable characteristics?

Element 2: the act or omission

Two definitions (WHO, CDC) explicitly refer to omissions or failure to act, which captures neglect, in addition to acts. The ANPEA definition explicitly refers to neglect in its explanatory statement. This is the only definition which in its primary description includes mention of specific types of abuse. The WHO definition indicates the acts may be single or repeated, which is the only reference to frequency in any of the three common definitions. The CDC includes clauses that provide expanded examples.

The literature on elder abuse and the responses to the Elder Abuse Prevalence Scoping Study demonstrates that a very broad range of actions and omissions may be considered elder abuse. These may occur across a range of domains, including physical abuse, psychological abuse, emotional abuse, economic abuse, financial abuse, sexual abuse, misuse of powers under legal and financial instruments and sexual abuse. Isolation was also raised, either in the context of care settings or as a tactic exerted to create opportunities for or conceal the occurrence of elder abuse. Prevention of access to culture or religion was also raised.

Several responses raised concerns about interactions between care needs and financial and housing interests, including circumstances where an older person was forced into care prematurely to provide access to housing assets or where obligations are not met in an asset to care arrangements.

Other responses raised concerns about Indigenous specific issues, including coercion and physical abuse perpetrated against older Aboriginal people, particularly women, by family members who want access to pension money.

Another category of acts and omissions raised include those that were described in the quotation above (section 3.2) as amounting to a denial of dignity and autonomy and specifically occur in hospital and care settings, such as restrictive practices. In relation to medical needs, a range of other acts and omissions are raised, including not complying with medication regimes appropriately, failing to seek appropriate medical care and being subjected to medical treatment for reasons other than the patient's own interests, denying access to mobility aids.

Responses indicated that neglect was a particularly complex phenomenon, including in situations of self-neglect, or where one older person was neglecting the needs of another because of the carer's cognitive decline.

Questions:

Variability and diversity: do the acts/omissions as described exclude any behaviours that should be included?

Measurement: does the formulation support the development of measures that can capture a meaningful range of acts/omissions?

Does it support the development of measures that will support specific issues being considered with specific populations?

Should questions in relation to frequency and severity be included to allow severe behaviour to be distinguished from less severe behaviour, particularly in order to understand empirical findings in relation to consequences?

Element 3: the person who engages in the behaviour (the actor)

The only definition of the three that explicitly refers to an actor is the CDC definition, which refers to a 'caregiver or another person in a relationship of trust'. In the other two definitions, the actor is implied in the situational pre-conditions, which in both definitions is an 'expectation of trust'. Divergence in views in a range of areas was evident in relation to this element in the responses to the Elder Abuse Prevalence Scoping Study. In particular:

• Not all responses supported the requirement for 'a relationship of trust', with some specifically indicating that this was too limiting. In contrast, some argued this was too broad. Others suggested this concept was an appropriate touchstone (see further discussion of Element 4).
• Some respondents suggested distinguishing between: friends, family members and neighbours and those whose relationship with the older person arose from a professional or contractual obligation, with responses varying on the justification for such a distinction to the extent discussion was provided.
• Some responses suggested scammers, including through online platforms, and tradespeople should be excluded but others argued the opposite, indicating that in such cases deliberate actions were pursed to support dishonest and exploitative actions.

Questions

Variability and diversity: does the description adopted unintentionally include or exclude categories of people?

Measurement: does the formulation in relation to the actor translate into meaningful measures?

Element 4: situational pre-conditions

Both the WHO and the CDC definitions are centred on an 'expectation of trust'. The ANPEA definition refers to an implication of trust. Responses to the survey conducted for the Elder Abuse Prevalence Scoping Study highlighted considerable divergence of views in relation to this element. This divergence emerged in relation to three issues: expectation of trust in itself, whether people in receipt of payment for services should be included or excluded even where an expectation or implication of trust is involved and whether situations involving scams, trades people and strangers selling services should be included.

In relation to people in receipt of payment for services, a majority (56%) considered that this group should be in scope, with mixed views as to whether a relationship of trust should be an additional requirement for this group.

One response, for example, suggested that three categories of relationship should be in contemplation:

1.Family and personal relationships

2.Carers and paid services providers

3.Relationships cultivated for the purposes of fraud, scamming or other criminal activities.

Other comments conveying the justification for the inclusion of scams included: 'building of personal relationships through online modalities builds an environment of trust and is exceptionally open to financial abuse'.

Some responses to the survey put forward additional or alternative situational pre-conditions, including:

• Exploitation of an imbalance of power and preying on age-related vulnerability
• Exercising influence should be included in the context of the person who is being influenced being vulnerable through ageing or old age
• Should be on vulnerability, isolation and dependence
• Conflict arising from self-interest and the actor's obligation to make good decisions for the elderly person.

These varied views indicate that further consideration of the question of a relationship or implication of trust as an element of elder abuse is warranted. The US National Research Council discussion in relation to this element made three particularly important points. First, that a relationship of trust may arise through voluntary assumption of responsibility or it may be imposed by law or social custom. Second, the threshold for the existence of a trust relationship may vary according the type of mistreatment involved. Third, that in some circumstances the existence of a trust relationship may be clear and in other cases ambiguous. The discussion highlighted the importance of research assessing the viewpoints of older people on whether relationships were trust relationships or not but concluded that ultimately objective assessment was required, with subjective assessment susceptible to being overridden by social convention and legal duties.

It concluded that further knowledge was required to support consideration of this element:

empirical knowledge is lacking about the kinds of trust relationships that older persons enter into, the other parties involved in these relationships, the foundations of these relationships, and their association with different types of mistreatment. Therefore, an early priority of research in the field ought to be the conceptual and empirical development of different operational definitions of trust relationships. (Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America, 2003)

The varied views of stakeholders reported in the Scoping Study reinforce the need for further research to inform thinking on this point.

Questions:

Variability and diversity: is the formulation flexible enough to cover situational pre-conditions that arise in relation to particular groups and communities?

Measurement: How can this element be measured? Is the presence or absence of a relationship of trust assessed from an objective or subjective (i.e. from the perspective of the person who has experienced the abuse) standpoint?

Element 5: Consequences

Each of the three definitions refers to the consequence of harm. The CDC definition contemplates actual harm or risk of harm. The ANPEA definition requires actual harm. The WHO definition requires either harm or distress. The Elder Abuse Prevalence Scoping Study indicated that a multi-dimensional concept of harm should be involved in the definition. Three quarters indicated physical harm, emotional harm and economic harm should be included and 67% also favoured the inclusion of social harm.

The Elder Abuse Prevalence Scoping Study indicated that distress would capture indirect effects of elder abuse and was considered subjective in nature. Responses indicated that it should be additional to harm but not essential.

Questions:

Variability and diversity: Does the formulation have the capacity to describe particular consequences for particular individuals and communities?

Measurement: Does the formulation support the development of empirically meaningful measures? Sh

Questions to guide data collections

Other elements

One definition, the CDC definition, refers to intention in committing acts or failing to act. The Elder Abuse Prevalence Scoping Study indicated little support for intention, which is a concept originating from criminal law. Around 60% of respondents to the Elder Abuse Prevalence Scoping Study Survey agreed that the definition applied in a prevalence study should support examination of both intended and unintended acts and omissions.

Structure

In addition to the content of core elements of the definition, the structure of elder abuse definitions is also a significant issue. Of the three considered in the Elder Abuse Prevalence Scoping Study, two (WHO and APNEA) involve a one-part structure in that the definition is contained in single clause. The CDC definition, in contrast, involves a primary clause specifying the core definition along with a secondary clause that describes specific types of elder abuse. Definitions with primary and further clauses are commonly used in family violence definitions contained in legislation (e.g. s 4AB Family Law Act 1975 (Cth)). Although they lack the simplicity of single clause definitions, they offer greater opportunity to capture the diversity of scope in elder abuse.

References

Australian Law Reform Commission, (2017). Elder Abuse - A National Legal Response. Sydney, ALRC.

Biggs, S., & Haapala, I. (2013). Elder mistreatment, ageism, and human rights. International Psychogeriatrics, 25(8), 1299-1306.

Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America. (2003). Retrieved from Washington: www.ncbi.nlm.nih.gov/pubmed/22812026/

Government of South Australia. (2014). Strategy to Safeguard the Rights of Older South Australians. Adelaide: Government of South Australia.

Lacey, W. (2014). Neglectful to the Point of Cruelty? Elder Abuse and the Rights of Older Persons in Australia. Sydney Law Review, 36.

McDonald, L., & Thomas, C. (2013). Elder abuse through a life course lens. International Psychogeriatrics, 25(8), 1235-1243.

Elder Abuse National Research (Questions for professionals)

Question guide for semi-structured discussions focus groups, workshops and individual or group interviews for people participating in their professional capacity.

Introduction script

1.When people use the term "abuse of older people", what do you think it means? When you think about the issues that cause concern about the treatment of older people that you/your organisation works with, does the term "abuse of older people" provide a good fit for describing them?

Probe: Why? Why not? Are there

2.If someone refers to an "elder" what does it mean to you?

Are there other ways of describing someone you think might be susceptible to being treated inappropriately by family, friends, carers or professionals?

Probe: If vulnerability is raised, ask how the group understands vulnerability and what causes it.

3.Can you describe actions and omissions that cause concern for your clients/organisation?

Probe: Depending on where focus of discussion has been, actively raise other types of abuse, such as: neglect, social isolation, abuse of legal/financial instruments, physical abuse, medical abuse.

4.In relation to the concerns we have discussed, who are the main people that the concerns arise from?

5.What do you understand by "a relationship of trust"? Does this term cover the situations that give rise to the concerns we discussed earlier? Are there other ways that these situations could be described?

6.Can you describe the consequences of the behaviour we have been talking about for the individuals that your organisation is concerned with?

7.This has been a really useful discussion. Is there anything else that anyone would like to raise?

Elder Abuse National Research (Questions to non-professionals)

Question guide for semi-structured discussions focus groups, workshops and individual or group interviews for people participating in a non-professional capacity.

Introduction script

1.Can we have a discussion about experiences that older people have that cause concern? I'd like to hear about the issues that are of concern for people in your community, in terms of the way they are treated by family, friends, carers or professionals.

Probe: do you think these issues are "abuse of older people"? What does the term abuse of older people mean to you?

2.If someone refers to an "elder" what does it mean to you?

Probe: How do you think the people that experience the kinds of behaviours that we have just been discussing should be referred to?

3.Thinking further about the question we asked at the beginning, about causes of concern for older people in your network or community, what are the other sorts of things that happen that create concern?

Probe: Depending on what issues discussions have focused on, raise other issues such as: neglect (are you aware of people who aren't being cared for properly?); social isolation (are you aware of people who are isolated?); abuse of legal/financial instruments? (are you aware of situations where people's wishes haven't been followed where someone else holds a legal/medical/financial power authority?).

4.In relation to the concerns we have just discussed, who are the main people that the concerns arise from?

5.I'd like to hear more about the situations and relationships in which behaviour causing the concerns that we just discussed arises. Can we discuss what it is about these situations and relationships that mean these concerns arise?

6.Could we talk more about the impact of these issues on the older people in your/network?

7.This has been a really useful discussion. Is there anything else that anyone would like to raise?