Definition, risk factors, recent research, assessment approaches and prevention strategies
This page has three sections:
Background Material that provides the context for the topic
A suggested Practice Approach
A list of Supporting Material / References
Feedback welcome!
Background Material
Definition (Pillemer et al., 2016; Kaspiew, 2016; Dean, 2019)
Elder abuse includes two major points: that an older person has suffered injury, deprivation, or unnecessary danger, and that another person (or persons) in a relationship of trust was responsible for causing or failing to prevent the harm. Researchers, practitioners, and most legal statutes recognize the following types of abuse:
physical abuse, which includes acts carried out with the intention to cause physical pain or injury;
psychological abuse, defined as acts carried out with the intention of causing emotional pain or injury;
sexual assault;
financial or material abuse, involving the misappropriation of the elder’s money or property; and
neglect, or the failure of a designated caregiver to meet the needs of a dependent older person.
Significant cultural variation exists in these five forms in which elder abuse appears.
The available evidence suggests that prevalence varies across abuse types, with psychological and financial abuse being the most common types of abuse reported. Results from studies suggest that the extent of elder abuse is sufficiently large that social service and health professionals who serve older adults are likely to encounter it on a routine basis. If prevalence rates remain the same, the absolute number of elder abuse incidents will rise in accordance with a rapidly growing older adult population.
Summary from Recent Research
Two surveys have been recently carried out in Australia that give a snapshot of the prevalence of elder abuse in both the community and in aged care settings.
1. Abuse of Older People living in the community
The National Elder Abuse Prevalence study (Qui et al., 2021) surveyed older people living in the community and, in its Executive Summary, presented an overview of elder abuse—including prevalence—that concisely summaries much of the material that follows in this Background Material section. In 2022 AIFS produced a number of resources delving more deeply into the prevalence of elder abuse in each of the abuse areas. These resources are available under AIFS (2022) in the References below.
The estimate for the prevalence of elder abuse among community dwelling people aged 65 and older in Australia is 14.8%, based on findings from the Survey of Older People. This estimate is based on experiences reported in the past year in the survey but is likely to be an under-estimate of the total prevalence because exclude people who lack cognitive ability and those in aged care settings. The most common form of abuse is psychological abuse (11.7%). Neglect is the next most common abuse subtype at 2.9%. For the other subtypes, prevalence rates are 2.1% for financial abuse, 1.8% for physical abuse and 1% for sexual abuse. Overall prevalence rates were similar for men and women.
Warning signs of elder abuse include (Roberts, 2022):
An older person seeming fearful, anxious or isolated
Evidence of injuries or lack of personal care
Disappearance of possessions
Unexplained financial transactions
Changes in a Will, Property Title, or other legal document
Someone taking control of an older person’s affairs when the older person still has capacity to express their wishes; the older person may have diminished capacity, but not no capacity.
Correlates of elder abuse include:
Low socio-economic status, associated with a greater risk of abuse overall, and especially financial, sexual and psychological abuse.
Owning a home with debt and/or being in rental accommodation (including public housing) are associated with a higher likelihood of experiencing psychological abuse and neglect. Conversely, owning a home without debt is associated with a lower likelihood of experiencing abuse.
Marital status is a consistent influence across all abuse types, with those who are either separated or divorced or living alone being more likely to experience abuse.
Poor health: including mental illness
Lack of social support and social contact
Elder abuse is mostly committed by family members, with adult children being the most common perpetrators (financial, physical and psychological abuse in particular), followed by intimate partners (physical, psychological and sexual abuse), then partners of adult children, and grandchildren to a much lesser extent. However, older people are also at risk of abuse from friends, neighbours and acquaintances; friends and acquaintances were the largest perpetrator groups for sexual abuse and also significant perpetrators for physical and psychological abuse. Men outweighed women as perpetrators of abuse by 10 percentage points overall, especially in relation to physical, sexual, and financial abuse.
Perpetrators were reported to have a range of problems: mental health problems (almost one third) and financial problems (nearly one fifth). For sexual abuse perpetrators, problems with alcohol predominated.
Help seeking is not a majority response: six in 10 people who experience elder abuse do not seek help with help less likely to be sought for neglect and sexual abuse. Eight in 10 people choose to speak to the perpetrator themselves. Not seeking help and managing elder abuse individually help to maintain a secrecy about elder abuse. Help and advice were mainly sought from family and friends.
Strategies to stop abuse often involve breaking contact with the perpetrator, but this can lead to a withdrawal from social life, with subsequent adverse consequences for contact with family, friends and support networks. If seeking professional help, older people were more likely to turn to the helping professions and medical professionals such as GPs and nurses.
Males are more accepting of elder abuse than females with this acceptance increasing with age. Acceptance was linked to lower education level, unemployment or retirement, low income and home ownership or rental. In terms of identification of abuse, financial and physical abuse was more likely to be identified than psychological abuse or neglect.
There is a need for policy and program development in the areas of prevention, awareness, identification and assessment of elder abuse with psychological abuse, sexual abuse and neglect warranting more attention. Key areas of focus would include increasing recognition and awareness of elder abuse behaviours. In addition, the socio-demographic characteristics associated with elder abuse, such as financial strain, housing stress and individual-level characteristics such as social isolation, mental ill health, poor physical health and disability indicate some directions for such a framework.
Because most elder abuse takes place in family relationships, measures to address it need to manage potential adverse consequences for the victim, such as isolation from family and friends.
There is a need for the assessment and development of responses to elder abuse. Proactive mechanisms to identify people who are experiencing elder abuse or are at risk of experiencing elder abuse are particularly important. Mechanisms should target the general public as well as health professionals. One mechanism could be systematic screening in, for example, health settings. But given the complex relationship dynamics involved in elder abuse, it is necessary to assess whether existing services are appropriately designed to address the problem.
2. Abuse of Older People in Aged Care Services
The Royal Commission in Aged Care and Safety (2020) produced the following summary for elder abuse in aged care services.
Risk Factors (Pillemer et al., 2016; Kaspiew et al., 2016; Dean, 2019)
A range of factors associated with older people, perpetrators, relationships and broader contextual factors contribute to older people’s risk of abuse and neglect. Emerging evidence suggests that social isolation and poor-quality relationships are among the main risk factors associated with elder abuse in community settings.
General risk factors for victims: cognitive impairment and disability, poor mental health, social isolation, history of abuse, family violence or conflict, part of a minority population, low income, poverty and poor physical health.
Physical abuse: age (<70), gender (female), low income, poor health, low social support, functional impairment/dependence, separated/divorced status, behavioural problems
Psychological or emotional abuse: lower age (<70), previous trauma experience, low social support, functional impairment/dependence, separated/divorced status
Sexual abuse: previous trauma experience, gender (female), low social support
Financial abuse: cognitive impairment, functional impairment/dependence, poor health, ethnic minority status, previous trauma experience, fear of loss of dependence, lack of protective scepticism of others
Neglect: low income, low social support, need for assistance, ethnic minority status, poor health, no use of social services, social isolation
Risk factors for perpetrators: caregiver stress, financial or emotional dependency on older adult, poor mental health, alcohol and other drugs, attitudes of entitlement (closely related to issues of ageism). An analysis of seven years of data from Seniors Rights Victoria (Joosten, 2020) (an advice call service for older people experiencing elder abuse) found
Sons and daughters were the most common perpetrators
Gender of abusers: 54% male and 46% female
36% of older people who experienced abuse lived with the perpetrator
Most common risk factors:
Perpetrators who are dysfunctional / over-burdened / isolated
Perpetrators with drug / alcohol / gambling issues
Perpetrator with mental health issues
Financial difficulties
Family history of violence
Physical abuse: dependency on older adult, history of family violence, employment status, poor mental health/psychological problems, social isolation, partner/spousal relationship, adult-child relationship
Psychological or emotional abuse: history of family violence, poor mental health/psychological problems, social isolation, partner/spousal relationship, substance misuse
Sexual abuse: history of family violence, poor mental health, social isolation, partner/spousal relationship, acquaintances
Financial abuse: history of family violence, family members, attitudes of entitlement, substance misuse
Neglect: previous trauma/family violence experience, carer stress/burden, reluctance in caregiving role, resentment towards older person, lack of caregiving skills, adult children
Relationship and contextual risk factors: family conflict and poor family relationships; social isolation; resident-to-resident abuse in institutional care settings; CALD people may face additional risks of abuse as a result of increased social isolation, language barriers and greater dependence on family members; broader societal factors such as ageism, inadequate health and social services for older people; economic pressure (e.g. intergenerational wealth disparities such as those between baby boomers and younger generations); and intergenerational conflict.
Consequences (Dean, 2019)
The main effects of elder abuse can include:
psychological distress and emotional difficulties (e.g. depression, fear, chronic stress)
disruptions in social and family relationships
compromised health
physical injury and hospitalisation
premature mortality
restrictions on, or elimination of, autonomy
changes in living arrangements
loss of assets and finances
There is little evidence of the various effects of elder abuse, not only on victims but also on family members. The impact of abuse can go undetected.
Assessment (Ernst, 2016)
When assessing older adults, social workers must keep in mind that:
Older adults are a very heterogeneous group, thus assessment processes must respond to the unique characteristics of each client
Social workers must recognize that the fear of losing autonomy may lead an older adult to minimize functional limitations.
If possible, conduct the assessment in the older adult’s environment. It increases the comfort level of the client and gives the social worker vital information as to how the individual functions. It also can assist in establishing trust. The client may want the presence of friends or family during the initial meeting, but their presence should be avoided if possible for privacy and confidentiality purposes. For instance, the client may be hesitant to disclose personal information in the presence of others. In a situation where abuse is suspected the social worker should interview the abused client without the presence of his/her caregiver, family, or suspected abuser.
Social workers can gain a lot of information by asking the client about a typical day. This way, the social worker can more naturally ask questions about who helps the client in carrying out day-to-day activities and can pick up cues about how well the older adult is being treated by family members, friends, and other caregivers. While conducting an assessment, social workers must keep in mind the risk factors for elder abuse.
Assessment should cover client information, functioning (ADLs), legal, physical environment, social supports, physical health, psychological health, and capacity. When doing a capacity assessment social workers are assessing the client’s ability to understand and follow instructions, understand risks and benefits, and make and execute a plan. Capacity assessment requires skill and training, and social workers should always consult supervisors to determine if referral to an expert is necessary.
There is an Australian screening instrument (AuSI) that can be used developed by NARI. Other instruments include the Hwalek-Sengstock Elder Abuse Screening Test (H-S/EAST) and the Elder Assessment Instrument (EAI)
Prevention
(Pillemer et al., 2016; Kaspiew et al., 2016; Dean, 2019; Bows & Penhale, 2018)
It is important to involve service users in decision making, but this often involves overcoming ageist assumptions from others who assume older people are unable or unwilling to participate in the process.
The ability to have a private conversation with people at risk of, or currently experiencing, abuse is one of the most important tools for social workers. This can be problematic, especially where the carer is the perpetrator.
Victims who do engage with services often present with a myriad of complex support needs. Therefore social workers need to accommodate these needs if a response is to be effective. There may be needs around reducing isolation and dependency and enlisting help and support; responding to and stopping abuse through to legal interventions and removing victims from unsafe settings, providing information, advice and support; and helping victims recover from abuse by medical treatment or health care, group or individual counselling, legal actions to recover property, counselling and support services. A multi-disciplinary approach may be necessary.
Reliable data (i.e. reliable randomized controlled intervention studies) does not exist for prevention interventions. It is vitally necessary that practitioners follow developments in the field, making them able to adopt evidence-based approaches as they are tested and disseminated. Emerging suggestions include:
Relieving the burden of caregiving for the older person, e.g. through housekeeping and meal preparation, respite care, education, support groups, and day care
Money management programs
Helplines
Broad prevention strategies involve changing the values and attitudes in the broader community, and mitigating the risk factors through measures to reduce social isolation, increase autonomy and empowerment, and support retention of control over financial affairs, or at the very least to help elders maintain knowledge of their financial affairs.
Practice Approach
A response to elder abuse should commence with a comprehensive bio-psych-social-spiritual assessment. The information above on assessment from Ernst (2016) will be relevant. Capacity assessment is important.
Horne (2022) highlights how important it is to adopt a person-centred approach with the person, to develop rapport and engage with him or her so they feel comfortable to disclose their concerns in an emotionally safe environment. Listening, validating and understanding the older person’s situation are essential skills. Important aspects of the BPSS to explore include age, health and mental health issues, the impact of intersectionality, family violence, and risk and safety concerns. Coupled with an understanding of an individual’s right to autonomy, social workers can support the older person to address the elder abuse in a way that is meaningful to them. A social work approach includes:
Understanding structural and systemic problems that affect older people (gender inequality, ageism, other discrimination preventing access to support). Advocacy skills to support older people to be active participants in their own lives may be needed.
Enabling older people to recognise family systems and relationships and assisting them to better manage these situations and make necessary changes
Recognising the barriers older people face in using systems (e.g. Commonwealth, state and local government) and support them to access appropriate support
There are a number of screening instruments available, copies of which can be sourced from the internet. The links are in the Supporting Material below.
Two sources intervention when elder abuse is suspected. The first (Kurrie, 2014) explores issues around victim capacity and considers three scenarios based on the victim’s capacity and willingness to accept interventions. The second, (Caxton Legal Centre, 2018) examines how social workers and lawyers can work together to assist the victim to make appropriate decisions to deal with elder abuse.
Kurrie's Approach
Caxton Legal Centre Approach
This approach is based on human rights: the older person has rights to autonomy and independence that are not diminished by the ageing process. The older person must be supported to exercise their right to self-determination.
The social worker is the first point of contact with the older person, and that same social worker maintains contact with the older person until the conclusion of the service. If legal issues are identified, and if the client wishes to obtain legal advice, the social worker will introduce them to a lawyer. Both the social worker and lawyer visit the client together, often at their home, aged-care facility, hospital or other safe place.
It is unusual to find that there are no legal issues involved in the circumstances of elder abuse. It is even more uncommon to find that the older person does not want legal advice, even if they later decide they do not wish to take legal steps to address the abuse. Where no legal advice is sought, the social worker provides non-legal support to address the social issues related to the abuse.
The client’s wishes and safety are always central to the assistance that is offered. They choose how to address the abuse they are experiencing from the suite of appropriate and available social and legal interventions presented. If they need ongoing legal assistance, the lawyer and social worker work together to plan with the client the legal steps that will be taken and the ongoing social supports that will be provided. This integrated case plan is reviewed continuously as the case progresses.
The Model At A Glance
[Older person is empowered as decision maker. High client retention occurs through the availability of a range of avenues for responding to elder abuse.]
Options for intervention (from Kurrie, 2014)
Options to prevent elder abuse are outlined in the theory section above. They include support services and financial management. Kurrie (2014) also includes these in a list of possible interventions. Ideally interventions seek to achieve freedom, safety, least disruption of lifestyle and include the least restrictive care alternatives. Possibilities include:
Crisis care, e.g. admission to an acute hospital bed or respite care in a nursing home
Provision of community support services, e.g. home nursing, housekeeping help, linkage programs, community transport
Provision of respite, e.g. in-home, day-centre or institutional respite.
Counselling, e.g. financial, individual or family therapy
Alternative accommodation on a permanent basis, e.g. institutionalisation for the victim
Legal interventions, e.g. criminal charges, Guardianship Tribunal applications
Collins et al. (2020), in a data mining study of elder abuse from records held by a Melbourne (Australia) public hospital found the three most common forms of intervention were
counselling for the vulnerable older person and their family when indicated,
provision of support services (in-home services such as cleaning and personal care, carer support services such as in-home respite care and carer support groups, and aged-care assessment team referrals for future care planning), and
information provision and education (about crisis support lines, legal options, pathways, and community supports for the VOP, their carer and the POC).
Supporting Material
(available on request)
AIFS: Australian Institute of Family Studies. (2022). Elder abuse in Australia: Prevalence. (Findings from the National Elder Abuse Prevalence Study). Melbourne: Australian Institute of Family Studies. https://aifs.gov.au/research/research-snapshots/elder-abuse-australia-prevalence
Elder abuse in Rural and Remote Communities. https://aifs.gov.au/resources/short-articles/elder-abuse-rural-and-remote-communities
Bows, H., & Penhale, B. (2018). Editorial: Elder abuse and social work: Research, theory and practice. British Journal of Social Work, 48, 873-886. doi: 10.1093/bjsw/bcy062
Caxton Legal Centre. (2018). Specialist elder abuse service: Social worker-lawyer intervention model; Seniors legal and support service. Retrieved from https://caxton.org.au/wp-content/uploads/2018/11/Specialist-Elder-Abuse-Service-Model-1.pdf
Collins, M., Posenelli, S., Cleak, H., O’Brien, M., Braddy, L., Donley, E., & Joubert, L. (2020). Elder abuse identification by an Australian health service: A five-year social-work audit. Australian Social Work, 73(4), 462-476, doi: 10.1080/0312407X.2020.1778050
This study suggests common care planning pathways that could be strengthened in a public hospital to better identify and support vulnerable older people.
Ensure internal referral pathways are in place, e.g. between subacute admissions and complex care teams.
Training sessions to provide information and education for staff are important to ensure staff are aware of resources such as crisis support lines, legal options and community supports.
Establish a health-justice partnership to provide onsite legal consultations for people experiencing or at risk of elder abuse.
Improve documentation regarding safety planning for VOPs (such as the provision of information and resources to improve personal, home and financial safety).
Place a screening question on admission forms to ask all patients (regardless of age) if they feel safe to return home from hospital.
Consider trialing the use of the Australian Elder Abuse Screening Instrument (AuSI). A pilot study of this tool showed improved staff confidence in screening for elder abuse and was helpful for frontline staff who usually screen for elder abuse. However the pilot showed that the AuSI had not effect on the detection of elder abuse cases and no effect on staff knowledge of elder abuse, which was already high. [Source: https://www.nari.net.au/ausi]
Dean, A. (2019). Elder abuse: Key issues and emerging evidence. Child Family Community Australia paper, 51.
Ernst, J. S. (2016). Elder justice: Curriculum modules for MSW programs. Council on Social Work Education. Retrieved from https://www.cswe.org/getattachment/Centers-Initiatives/Centers/Gero-Ed-Center/ElderJustice-CSWE-Gero-Ed.pdf.aspx
Horne, D. (2022). The value of social workers in elder abuse.Social Work Focus, 7(4), 22-23.
Joosten, M. (2020). Characteristics of elder abuse within the family: A seven-year trend analysis of Seniors Rights Victoria data. AIFS Snack Sized Research Showcase, presentation code 44. Retrieved from https://aifs.paperlessevents.com.au/
Kaspiew, R., Carson, R., & Rhoades, H. (2016) Elder abuse in Australia. Family Matters, 98. (AIFS) Retrieved from http://eds.a.ebscohost.com.ezproxy.utas.edu.au/eds/pdfviewer/pdfviewer?vid=3&sid=a8790329-a48a-4934-ab50-e49e7c507069%40sessionmgr4007
Kurrle, S. (2014). Intervention in a situation of elder abuse and neglect. In R. Nay, S. Garratt & D. Fetherstonhaugh. (Eds.). Older people: Issues and innovations in care (4th ed.) (pp. 347-358). Sydney, Australia: Elsevier Australia.
Pillemer, K., Burnes, D., Riffin, C., & Lachs, M. S. (2016). Elder abuse: Global situation, risk factors, and prevention strategies. The Gerontologist, 56(S2), S194-S205. doi:10.1093/geront/gnw004
Qu, L., Kaspiew, R., Carson, R., Roopani, D., De Maio, J., Harvey, J., & Horsfall, B. (2021). National Elder Abuse Prevalence Study: Final Report. (Research Report). Melbourne: Australian Institute of Family Studies. https://aifs.gov.au/research/research-reports/national-elder-abuse-prevalence-study-final-report See also the AIFS (2022) reference above.
Royal Commission into Aged Care Quality and Safety. (2020). Experimental estimates of prevalence of elder abuse in Australian aged care facilities. Research Paper 17. Retrieved from https://agedcare.royalcommission.gov.au/publications
Screening Instruments
Elder Assessment Instrument https://medicine.uiowa.edu/familymedicine/sites/medicine.uiowa.edu.familymedicine/files/wysiwyg_uploads/EAI.pdf
Hwalek-Sengstock Elder Abuse Screening Test
The Australian Elder Abuse Screening Instrument (AuSI) https://www.nari.net.au/ausi