Elder abuse is 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. This type of violence constitutes a violation of human rights and includes physical, sexual, psychological, and emotional abuse; financial and material abuse; abandonment; neglect; and serious loss of dignity and respect.

Scope of the problem

Elder abuse is an important public health problem. A 2017 study based on the best available evidence from 52 studies in 28 countries from diverse regions, including 12 low- and middle-income countries, estimated that, over the past year, 15.7% of people aged 60 years and older were subjected to some form of abuse (1).



This is likely to be an underestimation, as only 1 in 24 cases of elder abuse is reported, in part because older people are often afraid to report cases of abuse to family, friends, or to the authorities. Consequently, any prevalence rates are likely to be underestimated. Although rigorous data are limited, the study provides prevalence estimates, drawing on all available studies, of the number of older people affected by different types of abuse.



Data on the extent of the problem in institutions such as hospitals, nursing homes, and other long-term care facilities are scarce. However, systematic reviews and meta-analyses of recent studies on elder abuse in both institutional (2) and community settings (1) based on self-report by older adults suggests that the rates of abuse are much higher in institutions than in community settings (see Table 1).



Estimates of elder abuse and its subtypes in the institutions were calculated from all studies that collected data from staff as well as older adults and their proxies. A total of 9 studies in 6 countries based on staff self-reports on perpetrating abuse were analyzed together. The finding indicates that 64.2% of staff perpetrated some form of abuse in the past year. The self-reported estimates of elder abuse subtypes by staff and older residents suggest similarities in the magnitudes of the problem.



Table 1: Systematic reviews and meta-analyses





Elder abuse incommunity settings (1) Elder abuse in institutional settings (2) Type of abuse Reported by older adults Reported by older adults and their proxies Reported by staff Overall Prevalence 15.7% Not enough data 64.2% or 2 in 3 staff Psychological abuse: 11.6% 33.4% 32.5% Physical abuse: 2.6% 14.1% 9.3% Financial abuse: 6.8% 13.8% Not enough data Neglect: 4.2% 11.6% 12.0% Sexual abuse: 0.9% 1.9% 0.7%



Abusive acts in institutions may include physically restraining patients, depriving them of dignity (for instance, by leaving them in soiled clothes) and choice over daily affairs; intentionally providing insufficient care (such as allowing them to develop pressure sores); over- and under-medicating and withholding medication from patients; and emotional neglect and abuse.



• Elder abuse in community settings



• Elder abuse in institutional settings

Elder abuse can lead to physical injuries – ranging from minor scratches and bruises to broken bones and disabling injuries – and serious, sometimes long-lasting, psychological consequences, including depression and anxiety. For older people, the consequences of abuse can be especially serious and convalescence longer. Even relatively minor injuries can cause serious and permanent damage, or even death. A 13-year follow-up study found that victims of elder abuse are twice more likely to die prematurely than people who are not victims of elder abuse (3).



Globally, the number of cases of elder abuse is projected to increase as many countries have rapidly ageing populations whose needs may not be fully met due to resource constraints. It is predicted that by the year 2050, the global population of people aged 60 years and older will more than double, from 900 million in 2015 to about 2 billion, with the vast majority of older people living in low- and middle-income countries. If the proportion of elder abuse victims remains constant, the number of victims will increase rapidly due to population ageing, growing to 320 million victims by 2050.

Risk factors

Risk factors that may increase the potential for abuse of an older person can be identified at individual, relationship, community, and socio-cultural levels.

Individual

Risks at the individual level include poor physical and mental health of the victim, and mental disorders and alcohol and substance abuse in the abuser. Other individual-level factors which may increase the risk of abuse include the gender of victim and a shared living situation. While older men have the same risk of abuse as women, in some cultures where women have inferior social status, elderly women are at higher risk of neglect and financial abuse (such as seizing their property) when they are widowed. Women may also be at higher risk of more persistent and severe forms of abuse and injury.

Relationship

A shared living situation is a risk factor for elder abuse. It is not yet clear whether spouses or adult children of older people are more likely to perpetrate abuse. An abuser's dependency on the older person (often financial) also increases the risk of abuse. In some cases, a long history of poor family relationships may worsen as a result of stress when the older person becomes more care dependent. Finally, as more women enter the workforce and have less spare time, caring for older relatives becomes a greater burden, increasing the risk of abuse.

Community

Social isolation of caregivers and older persons, and the ensuing lack of social support, is a significant risk factor for elder abuse by caregivers. Many elderly people are isolated because of loss of physical or mental capacity, or through the loss of friends and family members.

Socio-cultural

Socio-cultural factors that may affect the risk of elder abuse include:

• ageist stereotypes where older adults are depicted as frail, weak and dependent;

• erosion of the bonds between generations of a family;

• systems of inheritance and land rights, affecting the distribution of power and material goods within families;

• migration of young couples, leaving older parents alone in societies where older people were traditionally cared for by their offspring; and

• lack of funds to pay for care.





Within institutions, abuse is more likely to occur where:



• standards for health care, welfare services, and care facilities for elder persons are low;

• staff are poorly trained, remunerated, and overworked;

• the physical environment is deficient; and

• policies operate in the interests of the institution rather than the residents.

Prevention

Many strategies have been implemented to prevent elder abuse and to take action against it and mitigate its consequences. Interventions that have been implemented – mainly in high-income countries – to prevent abuse include:



• public and professional awareness campaigns

• screening (of potential victims and abusers)

• school-based intergenerational programmes

• caregiver support interventions (including stress management and respite care)

• residential care policies to define and improve standards of care

• caregiver training on dementia.



Efforts to respond to and prevent further abuse include interventions such as:



• mandatory reporting of abuse to authorities

• self-help groups

• safe-houses and emergency shelters

• psychological programmes for abusers

• helplines to provide information and referrals

• caregiver support interventions.



Evidence for the effectiveness of most of these interventions is limited at present. However, caregiver support after abuse has occurred reduces the likelihood of its reoccurrence and school-based intergeneration programmes (to decrease negative societal attitudes and stereotypes towards older people) have shown some promise, as have caregiver support to prevent elder abuse before it occurs and professional awareness of the problem. Evidence suggests that adult protective services and home visitation by police and social workers for victims of elder abuse may in fact have adverse consequences, increasing elder abuse.



Multiple sectors and interdisciplinary collaboration can contribute to reducing elder abuse, including:



• the social welfare sector (through the provision of legal, financial, and housing support);

• the education sector (through public education and awareness campaigns); and

• the health sector (through the detection and treatment of victims by primary health care workers).



In some countries, the health sector has taken a leading role in raising public concern about elder abuse, while in others the social welfare sector has taken the lead.



Globally, too little is known about elder abuse and how to prevent it, particularly in developing countries. The scope and nature of the problem is only beginning to be delineated. Many risk factors remain contested, and the consequences and evidence for what works to prevent elder abuse is limited.

WHO response

In May 2016 the World Health Assembly adopted a Global strategy and action plan on ageing and health that provides guidance for coordinated action in countries on elder abuse that aligns with the Sustainable Development Goals.



In line with the Global strategy WHO and partners collaborate to prevent elder abuse through initiatives that help to identify, quantify, and respond to the problem, including:



• building evidence on the scope and types of elder abuse in different settings (to understand the magnitude and nature of the problem at the global level), particularly in low- and middle-income countries from Southeast Asia, the Middle East, and Africa, for which there is little data;

• collecting evidence and developing guidance for Member States and all relevant sectors to prevent elder abuse and strengthen their responses to it;

• disseminating information to countries and supporting national efforts to prevent elder abuse; and

• collaborating with international agencies and organizations to deter the problem globally.



(1) Elder abuse prevalence in community settings: a systematic review and meta-analysis.

Yon Y, Mikton CR, Gassoumis ZD, Wilber KH. Lancet Glob Health. 2017 Feb;5(2):e147-e156.

https://www.ncbi.nlm.nih.gov/pubmed/28104184

(2) The prevalence of elder abuse in institutional settings: a systematic review and meta-analysis. Yon Y, Ramiro-Gonzalez M, Mikton C, Huber M, Sethi D. European Journal of Public Health 2018.

https://www.ncbi.nlm.nih.gov/pubmed/29878101

(3) The mortality of elder mistreatment.

Lachs MS, Williams CS, O'Brien S, Pillemer KA, Charlson ME. JAMA. 1998 Aug 5;280(5):428-32.

https://www.ncbi.nlm.nih.gov/pubmed/9701077