Chapter 17: Relationship Violence Against Older Adults
Balbir Gurm; Glaucia Salgado; and Jennifer Marchbank
- The older adult population in Canada and around the world is increasing, and elder abuse is recognized as a public health, and a pervasive social issue.
- Relatives, friends and caregivers are often the perpetrators of elder abuse.
- Types of relationship violence with older adults include: physical, sexual, emotional or psychological, neglect, financial or exploitation, violation of Rights and Freedoms and systemic abuse.
- Many older adults experience social isolation. Social isolation is a common risk factor for RV.
- Protective and risk factors exist and intersect at the individual, relational, community and societal levels.
- Elder abuse prevention and intervention initiatives have not received enough research attention, so there are many recommendations, but very few evaluations done to understand its applicability and outcomes.
Relationship violence is any form of physical, emotional, spiritual and financial abuse, negative social control or coercion that is suffered by anyone that has a bond or relationship with the offender. In the literature, we find words such as intimate partner violence (IPV), neglect, dating violence, family violence, battery, child neglect, child abuse, bullying, seniors or elder abuse, male violence, stalking, cyberbullying, strangulation, technology-facilitated coercive control, honour killing, female genital mutilation gang violence and workplace violence. In couples, violence can be perpetrated by women and men in opposite-sex relationships (Carney et al., 2007), within same-sex relationships (Rollè et al., 2018) and in relationships where the victim is LGBTQ2SIA+ (lesbian, gay, bisexual, transgender, queer, Two-Spirit, intersex and asexual plus) (The Scottish Trans Alliance, 2010; Rollè et al., 2018). Relationship violence is a result of multiple impacts such as taken for granted inequalities, policies and practices that accept sexism, racism, ageism, xenophobia and homophobia. It can span the entire age spectrum. It may start in-utero and end with death. Relationship violence impacts the physical, psychological, economic and social wellbeing of those who are abused (see chapter 5), their families, communities and society. This chapter provides a closer look at elder abuse, risk factors and some resources.
Relationship Violence in Older Adults – Elder Abuse
The older adult population in Canada and around the world is increasing, and relationship violence among this population group is recognized as a public health and pervasive social issue. Relationship violence against older adults is called elder abuse. It is defined as “a single, or repeated act, or lack of appropriate action, occurring within any relationship in which there is an expectation of trust causing harm or distress to an older person—aged 60 years and older” (World Health Organization [WHO], 2017). Also, the terms elder maltreatment and elder mistreatment are used to describe elder abuse (Acierno et al., 2001). It is important to note that older adults are a heterogeneous population group, and risks of elder abuse might vary among different age groups.
Definitions and Incidence
Elder abuse can be broken down into different types of abuse. Physical abuse refers to acts of violence or the use of physical force against an older adult; for instance, hitting, pushing, kicking, punching, grabbing or handled roughly and inappropriate use of drugs and physical restraints to exert control over an older individual.
In Canada, victims of physical abuse are often Aboriginal seniors, divorced older people, cognitively impaired or physically disabled, low-income seniors and those who live in rural areas (Brozowski1 & Hall, 2010; McDonald, 2011). Rates of physical abuse vary across the globe, and countries of Africa and Europe have the highest percentages; 15% in Nigeria, and 13% in the UK and Northern Island (WHO, 2017). Factors affecting the prevalence of physical abuse are also associated with gender. Research shows that older women and LGBTQ older adults are considerably affected by physical abuse, with estimates reaching up to 42% among LGBTQ seniors (MAP, 2009). Furthermore, physical violence against older adults is often accompanied by other forms of abuse, the most prevalent being psychological and financial abuse (Elder Abuse Organization, 2019).
Psychological abuse is sometimes called emotional abuse, and it is characterized by attempts to intimidate or belittle an older person using insults, verbal threats, ignoring, withholding critical support or service, trying to control their choices and freedom, treating them as a child and not allowing them to see family and friends (WHO, 2019). The prevalence of psychological abuse is alarming around the world. Countries like the UK and Northern Island, China, Croatia, and Spain have the highest rates: 38%, 27%, 24%, and 15%, respectively (WHO, 2017). Psychological abuse is associated with low social support, financial strain and low education level. Countries that provide little or no social assistance to caregivers of vulnerable older adults have the highest rates of psychological abuse (Macassa et al., 2013). As it occurs with physical abuse among the LGBT older population, psychological abuse is extremely high in this population, especially among transgender older adults. A study reveals that almost 80% of transgender seniors report having suffered verbal violence (MAP, 2009).
Sexual contact/abuse or event that happens without the consent of an older adult, not being allowed to have personal privacy or verbal/suggestive behaviour is defined as sexual abuse.
Elder sexual abuse includes any unwanted sexual interaction like touching an older adult with sexual intention or someone touching him/herself sexually in front of an older adult, unwanted conversations with sexual content and sexual activity with an older adult who either does not consent or is unable to do so (WHO, 2019). Elder sexual abuse has been suggested to be less prevalent than other forms of violence (Acierno et al., 2010; WHO, 2019). However, the low number of studies on sexual abuse among the older population is a critical barrier to understanding its incidents and impact (WHO, 2017).
Bows (2018) reviewed published studies, and found rates of sexual violence vary between 0.9-8% for older women. Dong (2005) reported abuse across North and South America, 10% to 47.3% with a higher incidence for those with dementia. The National Council on Aging (n.d.) states that 1 in 10 older adults in the US suffers elder abuse. Burnes et al. (2019) estimated that only 15.4% report to the police, with fear of revictimization being cited as the most prevalent reason. Some other reasons are an embarrassment, fear, denial, isolation, lack of resources, or lack of knowledge about reporting procedures. Physically being capable of reporting is also a barrier for some older adults as they may have to rely on others (their abusers) for mobility and to communicate due to age-related health issues.
Financial abuse is also known as financial exploitation. It is misuse or stealing money, property or other assets or possessions by tricking, threatening or persuading or miss using a power of attorney. It is a violation of rights and freedoms- not being able to make a choice that is protected under the law such as the end of life. The most common type of RV is financial (CNPEA, 2017; Weissberger et al., 2019).
Often, family members or people who have a close relationship with the older adult are the perpetrators who see the behaviour as acceptable due to their “sense of need, entitlement or greed” (HealthLinkBC, 2018). Financial abuse includes but is not limited to, illegal use of debit or credit cards, unauthorized cashing out of an older adult’s pension or other forms of financial gain, deceiving an older person to signing documents with monetary value and controlling an older adult’s financial resources (Lachs & Pillermer, 2015; NCEA, n.d.). Financial abuse has been associated with low-income population groups, and it is the most reported type of abuse and is expected to increase even more due to the increase in the older adult population (DeLiema et al., 2012; Jackson & Hafemeister, 2013). When an older adult is a victim of financial abuse, he/she might have their basic needs like food, shelter and medical care unmet, causing a significant negative impact on their health and quality of life (National Institute on Aging, 2016). Although some developing countries show the highest rates of financial elder abuse like Brazil (14,4%) and Nigeria (13%), Canada and the US have similar prevalence as India and Thailand with 5% and 6%, respectively (Santos et al., 2019; WHO, 2017).
In the United States, the health care cost of elder abuse is estimated at $5.3 billion (Dong, 2005). As with all RV, it is difficult to estimate the true scope of the issue because it is vastly under-reported. Savage (2018), based on Canadian Statistics of 2018, shows that from 12,202 police-reported cases—45% female versus 56% male—33% were abused by a family member most often spouse, followed by an adult child. Reasons reported as triggers of abuse were linked to anger, frustration, despair and argument.
Elder neglect refers to either intentional or unintentional failing or refusal of a caregiver to meet an older person’s physical, emotional and social needs. Caregivers might be a family member like a spouse, daughter, or son or a paid professional who is responsible for providing regular help to a person who needs personal and health care either in their home or at a care facility (Wister & McPherson, 2014). Some examples of elder neglect are failing to give medication, bathing, toileting, and dressing, stopping essential health treatment, consciously ignoring an older person and failing to provide appropriate food and water (NCEA, n.d.). Neglect is extremely common among older adults who have more complex health problems like dementia or decreased physical/psychological ability. There are significant discrepancies of neglect among different genders. For example, women and older adults who self identify as LGB are at the highest risk of elder neglect (Grossman et al., 2014; Lacher et al., 2016; McDonald, 2011). The higher life expectancy for women compared to men and the higher chances of requiring a caregiver are one reason for the gender difference between men and women (McDonald, 2011). In the case of LGB, Frazer (2009) suggests that caregivers’ prejudice against LGB identity and homophobic views are considered crucial reasons of neglect among this population group.
Neglecting an older person’s needs can lead to physical and emotional problems like malnutrition, serious health problems that require hospitalization, early institutionalization, and in severe cases, death (Del Carmen & LoFaso, 2014; Dong et al., 2011; Friedman et al., 2011; Rovi et al., 2009). It is essential to understand that older adults may engage in self-neglect and self-abuse behaviours. Although self-neglect and self-abuse are connected to family relationships and lack of social support, other complex issues may exist (McDonald, 2011).
Spiritual abuse is behaviours that prevent or “denigrate individuals from practicing their cultural and spiritual beliefs” (The Grandmother Spirit Project, 2011 p.4). For example, every time an older family member wishes to go to the Gurdwara to worship, their family makes up an excuse for why they cannot drop him off and the person never gets to go to the Gurdwara.
Systemic abuse refers to institutional “rules, regulations, policies and social practices that harm or discriminate against older adults” (The Canadian Network for the Prevention of Elder Abuse, 2017). Although examples of systemic abuse are often associated with one of the more general criteria, for instance, using medication to control challenging behaviours due to lack of staff is related to physical abuse, systemic or institutionalized abuse represents a distinct issue. Practices and consequences of systemic abuse become normalized and justified creating an oppressive system that is challenging to recognize and contest. Consequently, institutionalized abuse turns into a pervasive and enduring issue.
Weissberger et al.’s (2019) frontline study, at a call centre where survivors only identified one form of abuse, found the rates of reporting were as follows: (49.5%) financial abuse, (13%) neglect, (12.5%) emotional abuse, (5.1%) reported physical abuse, sexual abuse (0.8%) and self-neglect (0.8%). Also, the same study found that 23% of the calls reported more than one type of abuse, in the following order: physical, emotional abuse, sexual abuse, neglect, self-neglect, and emotional abuse and quite often occurred with physical and financial; and neglect most often co-occurred with financial, followed by emotional abuse (Weissberger et al., 2019).
According to a systematic review by Viergever et al. (2018), 141 million older adults around the world are abused, in contrast with the figure of 1.4 billion women around the world. Yon et al. (2017) examined data from 28 countries and found that elder abuse is prevalent and under-reported. After assessing 52 publications, findings show a global prevalence of almost 16% between 2002 to 2015. Although this rate is considered critical, this number might be even higher due to significant gaps in estimating the prevalence of elder abuse. Disagreement in defining and measuring elder abuse is suggested to be a key factor affecting variations in reported prevalence (Dong, 2005). Prevalence statistics are hard to predict because studies are often done on small and non-representative samples. Also, in many countries, crimes reported to the police are not labelled as elder abuse, nor do reports always include the victims’ age (McDonald, 2011).
For many reasons, it may be difficult for an older adult to tell someone that they are being abused. For how to tell someone, click here (Seniors British Columbia, n.d.). Elder abuse is underreported and the consequences are ill health, hospital and care home admissions and death.
The abuse of older adults is considered a major public health problem that is associated with adverse health outcomes such as the increased risk of morbidity and mortality (Dong et al., 2011; Jerliu et al., 2013). Besides severe, long-lasting health consequences, inflicting harm to older individuals has significant implications for the health care and criminal justice systems that are costly to address (Aged Rights Advocacy Service [ARAS], 2019; Dong & Simon, 2013).
Yunus et al. (2017) conducted a systematic review to understand the consequences of elder abuse and neglect. They searched 7 data banks and eventually narrowed it to 19 studies. Within these studies, they found abuse can result in deaths, hospitalization, emergency room visits and use of health and social services. They also found that in some studies “older women, in general, were materially and socially disadvantaged compared to older men” and older women “had higher levels of severe disability and poorer living arrangements” (p. 209).
Below is a list of consequences of abuse from Yunus et al. (2017):
- emergency room visits
- Use of health and social services
- Decrease in
- Physical health
- Physical function
- Mental health
- Psychological health
- Depressive symptomatology
- Psychological distress
- Negative emotional symptoms
- Negative self-rated health
- Musculoskeletal pain
- Stomach problems
- Sleeping problems
- Suicidal ideation
- Suicidal attempt
- Digestive problems
- Metabolic syndrome
- Chronic pain
- Somatic complaints
- Social dysfunction
It is important to understand the risk factors of RV in order to intervene and assist. They can be used to create prevention programs. It is important to recognize that the factors discussed below are what contributes to risk, they are not causes.
According to the Angus Reid Institute (2019), social isolation is experienced by 62% of all Canadians and that maybe even higher among older adults. Social isolation is a common risk factor for RV as the older adult may not wish to complain due to fear of losing their minimal social contacts and family members.
Blundell and Warren (2019) Australian study found that living in a rural and isolated community also increases risk as well as limits access to services. Crowder et al. (2019) conducted an integrative review of elder abuse in Indigenous populations in the US and found that substance abuse, mental health problems and caregiving were common risk factors. Caregivers get burned out and are at risk of abusing the person who they are caring for.
Storey (2019) conducted a meta-analysis to identify risk factors for elder abuse for those being abused and for perpetrators. She reviewed 198 studies and synthesized eight common risk factors for perpetrators:
- Challenges with physical health
- Challenges with mental health
- Substance use
- Stress and coping
- History of abuse
- Holding negative attitudes towards older adults
- Relationship problems
Risk factors among victims of elder abuse were identified as challenges with physical health, mental health, stress and coping, an attitude of self-blame, a history of abuse, and relationship problems (Storey, 2019). It is interesting that four of the risk factors are the same for perpetrators and those being abused. Read her full review, click here.
The CDC (2019) has also identified both protective and risk factors and organized them as an individual, relational, community and societal, see below.
Risk Factors for Perpetrators
- Current diagnosis of mental illness
- Current abuse of alcohol
- High levels of hostility
- Poor or inadequate preparation or training for caregiving responsibilities
- Assumption of caregiving responsibilities at an early age
- Inadequate coping skills
- Exposure to abuse as a child
- Relationship level
- High financial and emotional dependence upon vulnerable older adults
- Past experience of disruptive behaviour
- Lack of social support
- Lack of formal support
Formal services, such as respite care for those providing care to older adults, are limited, inaccessible, or unavailable.
Societal Level – a culture in which:
- There is a high tolerance for, and acceptance of, aggressive behaviour
- Health care personnel, guardians, and other agents are given greater freedom in routine care and decision making
- Family members are expected to care for older adults without seeking help from others
- Persons are encouraged to endure suffering or remain silent regarding their pains
- There are negative beliefs about aging and older adults
In addition to the above factors, there are specific characteristics of institutional settings that can increase the risk for perpetration of vulnerable older adults, including:
- Unsympathetic or negative staff attitudes toward residents
- Chronic staffing problems
- Lack of administrative oversight, staff burnout, and stressful working conditions
Protective Factors for Perpetrators
Protective factors reduce the risk of perpetrating abuse and neglect. These protective factors have not been studied as extensively or rigorously as risk factors. However, identifying and understanding them are equally as important as researching risk factors. Research is needed to determine whether these factors do, indeed, buffer older adults from abuse.
- Having numerous, strong relationships with people of varying social status
- Coordination of resources and services among community agencies and organizations that serve the older adult population and their caregivers
- Higher levels of community cohesion and a strong sense of community or community identity
- Higher levels of community functionality and greater collective efficacy
- Effective monitoring systems
- Solid institutional policies and procedures regarding patient care
- Regular training on elder abuse and neglect for employees
- Education and clear guidance on the durable power of attorney, and how it is to be used (For BC, access The Adult Guardianship Act here. It included a specific section on Support and Assistance for Abused and Neglected Adults)
- Regular visits by family members, volunteers, and social workers (CDC, 2019)
Gerino and colleagues (2018) found that having social support, adopting help-seeking behaviours, and having access to community-based services are critical factors in addressing abuse experienced among older adults. Access the systematic literature review here.
Ryan and Roman (2019) did a review of studies that used a family centred approach because they asserted that abuse is done by families, but services are oriented towards professionals. They reviewed interventions for families and found that interventions that use a multisystem approach, address culture and involve community can be effective approaches.
Initiatives and Resources
Elder abuse initiatives have not received enough research attention. Although there are many recommendations, there are very few evaluations done to understand their applicability and outcomes, especially in the prevention field (Ploeg et al., 2009; Sethi et al., 2011). Overall, initiatives include educational programs, legislation and policies, programs to increase detection and rehabilitation and emotional support to victims (Baker et al., 2016).
A systematic review that analyzed programs dated from 1982 – 2017 show that most (74%) were focused on educational interventions and 57% reported impacts. They found that many programs did not use a good study design and it was challenging to establish long-term impacts (Rosen et al., 2019). We recommend that those who design and implement programs work closely with researchers in order to design high-quality evaluations. Although we have stated that there are no published effective programs according to the meta-analysis done by Rosen et al. (2019), there are resources to get help.
There are a number of resources for older adults. If there is imminent danger, call 911. If you just want to talk to someone and get resources, call the Seniors Abuse and Information Line call: 604-437-1940 or Toll-Free: 1-866-437-1940. You can call 7 days a week 8 AM – 8 PM in BC (Seniors First BC, 2019). You can also visit the Government of British Columbia’s (n.d.) Protection from Elder Abuse and Neglect website.
It is assumed that adults are capable of making their own decisions unless, for some reason, they are impaired. To read about guardianship click here, to read The Adult Guardianship Act, click here.
To find more information about how to support an older adult who discloses experiencing abuse, please, click here (Responding to Elder Abuse) for a quick note on how to respond and click here (Responding Safely to Situations of Relationship Violence) for a comprehensive learning module on how to learn how to respond (Government of British Columbia, n.d.).
There have been resources created specifically to educate about elder abuse in the LGBTQIA+ community. NEVR member Jennifer Marchbank was part of this project to create Canada’s first educational materials on elder abuse in this demographic. Please, check this link (Simon Fraser University) to find information and download materials (Gerontology Research Centre Simon Fraser University, n.d.).
Services and Organizations
Table 16.1 – List of Programs in Canada
|Seniors First British Columbia||Seniors First BC||This organization provides three main types of services, including education about elder abuse, programs to support victims, and legal support to low-income older adults (Seniors First British Columbia, n.d.).|
|Canadian Network for the Prevention of Elder Abuse||CNPEA Project||The Canadian Network for the Prevention of Elder Abuse is a platform in Canada that includes a range of resources available on elder abuse. Information includes, but it is not limited to, reports on violence against women and older women, government strategies to address elder abuse, rights and legal information related to sexual assault, tools for the development of practices in community settings, and education on elder abuse among visible minority groups in Canada. All educational resources, like studies and webinars, are available for free online. Content of educational material includes seniors bullying, a guidebook to safety and security on streets and against scams, and legal toolkits that explain how the court system works and how to access it (CNPEA, 2017).|
|International Institute for Restorative Practices||The Waterloo Restorative Justice Project||The Waterloo Restorative Justice Project is an initiative developed in Waterloo, ON Canada. This initiative focuses on mediating practices of reconciliation between victims and offenders. Through a restorative approach, it aims to increase reporting cases of elder abuse and supporting victims to deal with traumatic experiences. The Restorative Practices approach focuses on improving, repairing and developing healthier relationships between seniors and the community. The project includes community education to help seniors, families, and individuals who work with older adults to understand, recognize and know what can be done when an older adult is facing elder abuse (International Institute for Restorative Practices, n.d.).|
Table 16.2 – List of Programs outside Canada
|Aged Rights Advocacy Service Inc.||Abuse Prevention||Through educational workshops to older adults and their families/friends, and training sessions to professionals who work with seniors, ARAS tries to raise awareness about the types of elder abuse, older adults’ rights, and strategies to reduce and eliminate elder abuse cases (ARA, 2019)|
|Government of Australia||Older Persons Advocacy Network Programs||OPAN offers specific programs like the Elder Abuse Prevention program and advocacy in cases of elder abuse (Government of Australia, n.d.).|
|Bet Tzedek Legal Services||Elder Law Clinic||The Bet Tzedek Elder Law Clinic established in 1974 due to the high demand for legal service among older adults who survived the Holocaust, and other low-income seniors in the state of California, US (Bet Tzedek Legal Services (n.d.).|
|National Adult Protective Services Association||Vulnerable Elders Protection Team||It intends to identify elder abuse cases during a hospital visit. The service consists of offering consultations to physicians, nurses and social workers to support assessing and identifying signs of abuse among older patients (National Adult Protective Services Association, n.d.).|
|NYC Elder Abuse Center||Elder Abuse Helpline for Concerned Persons||The service provides counselling and guidance to older adults, or any individual who might be concerned about an older adult is a victim of abuse (NYC Elder Abuse Center, n.d.).|
|University College London – UK||The START – Strategies for Relatives||The program includes weekly psychological therapy for a total of 8 weeks. Each session is delivered by a psychology graduate student who receives training and supervision assistance (Knapp et al., 2013).|
|Washington State Department of Health||Stay Active for Life Program||The SAIL is a falls prevention program designed to support older adults to stay active, healthy and independent (SAIL, n.d.).|
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