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Series Editors: Jason L. Powell, Sheying Chen
International Perspectives on Aging 24
AmandaPhelan Editor
Advances in
Elder Abuse
Research
Practice, Legislation and Policy
International Perspectives on Aging
Volume 24
Series Editors
JasonL.Powell, Department of Social and Political Science, University of Chester,
Chester, UK
SheyingChen, Department of Public Administration, Pace University,New York,
NY,USA
The study of aging is continuing to increase rapidly across multiple disciplines. This
wide-ranging series on International Perspectives on Aging provides readers with
much-needed comprehensive texts and critical perspectives on the latest research,
policy, and practical developments. Both aging and globalization have become a
reality of our times, yet a systematic effort of a global magnitude to address aging is
yet to be seen. The series bridges the gaps in the literature and provides cutting- edge
debate on new and traditional areas of comparative aging, all from an international
perspective. More specically, this book series on International Perspectives on
Aging puts the spotlight on international and comparative studies of aging.
More information about this series at http://www.springer.com/series/8818
Amanda Phelan
Editor
Advances in Elder Abuse
Research
Practice, Legislation and Policy
ISSN 2197-5841 ISSN 2197-585X (electronic)
International Perspectives on Aging
ISBN 978-3-030-25092-8 ISBN 978-3-030-25093-5 (eBook)
https://doi.org/10.1007/978-3-030-25093-5
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Editor
Amanda Phelan
National Centre for the Protection of Older People,
School of Nursing, Midwifery & Health Systems
University College Dublin
Beleld, Dublin, Ireland
In memory of my mother,
Frances Phelan
vii
Acknowledgments
This book has been a journey of discovery. I am fortunate to have colleagues who
agreed to write illuminating chapters within their expert areas. This has allowed me
to present readers with a full account of the current knowledge, practice, legislative,
and policy in the area of elder abuse and safeguarding. For this, I am truly grateful.
I would like to thank Professor Gerard Fealy, School of Nursing, Midwifery, and
Health Systems, University College Dublin, for his support for this book.
A nal thanks to my husband, Gary, and children, Amy, Aoife, and Jack, who
have always been my inspiration.
ix
Contents
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Amanda Phelan
2 The Intersection of Ageism and Elder Abuse . . . . . . . . . . . . . . . . . . . . 11
Amanda Phelan and Liat Ayalon
3 Person Centred Approaches in Capacity Legislation . . . . . . . . . . . . . 23
Amanda Phelan and Patricia Rickard-Clarke
4 Elder Abuse in Israeli Society – Legislative Acts
and Special Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Ariela Lowenstein and Israel (Issi) Doron
5 Elder Abuse Policy, Past, Present, and Future Trends . . . . . . . . . . . . 53
Pamela B. Teaster, Brian W. Lindberg, and Yuxin Zhao
6 ‘If You Do Not Believe That It Happens You Won’t See
It Either!’-Sexual Abuse in Later Life . . . . . . . . . . . . . . . . . . . . . . . . . 73
Wenche Malmedal
7 Self-Neglect in Older Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Mary Rose Day
8 Financial Abuse of Older People . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Amanda Phelan
9 Keep Control: A Co-designed Educational and Information
Campaign Supporting Older People to Be Empowered
against Financial Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Deirdre O’Donnell
10 Elder Abuse and Dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Claudia Cooper and Gill Livingston
x
11 Elder Abuse in the LGBT Community . . . . . . . . . . . . . . . . . . . . . . . . . 149
Gloria M. Gutman, Claire Robson, and Jennifer Marchbank
12 Gender Issues in Elder Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Bridget Penhale
13 Danger in Safe Spaces? Resident-to- Resident
Aggression in Institutional Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
Thomas Goergen, Anja Gerlach, Sabine Nowak,
Anna Reinelt- Ferber, Stefan Jadzewski, and Anabel Tae
14 An Ecological Perspective on Elder Abuse Interventions . . . . . . . . . . 193
Amanda Phelan and Deirdre O’Donnell
15 The Public Health Approach to Elder Abuse Prevention
in Europe: Progress and Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
Yongjie Yon, Janice Lam, Jonathon Passmore, Manfred Huber,
and Dinesh Sethi
16 Human Rights and Elder Abuse: The Case Example of Serbia . . . . . 239
Natasa Todorovic and Milutin Vracevic
17 The Emerging Role of Independent Advocacy
in Responding to Issues Affecting Older People in Ireland . . . . . . . . . 253
Mervyn Taylor
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
Contents
xi
Abbreviations
ACA Affordable Care Act
ACL Administration for Community Living
ADL Activities of Daily Living
AEA Action on Elder Abuse
AGSS Abrams Geriatric Self-Neglect Scale
AoA Administration on Aging
APS Adult Protective Services
CBS Central Bureau of Statistics
CHAP Chicago Health and Aging Project
CIS Commonwealth of Independent States
CPHNA Community Prole and Health Needs Assessment
DH Department of Health
DOJ Department of Justice
DSM Diagnostic and Statistical Manual
DSM-5 Diagnostic and Statistical Manual of Mental Disorders
EJA Elder Justice Act
EJCC Elder Justice Coordinating Council
EJI Elder Justice Initiative
ESNA Elder Self-Neglect Assessment
EU European Union
FA Financial Abuse
FAST Financial Abuse Specialist Team
GAO Government Accountability Ofce
GP General Practitioner
HHS Health and Human Services
HSE Health Service Executive
HIC High-Income Country
HIQA Health Information and Quality Authority
HMO Community Health Clinic
INPEA International Network for the Prevention of Elder Abuse
IPV Intimate Partner Violence
xii
LGBT Lesbian, Gay, Bisexual, and Transgender
LGBTQ Lesbian, Gay, Bisexual, Transgender, and Queer
LGBTQ2SIA+ Lesbian, Gay, Bisexual, Transgender, Questioning/Queer, Two-
Spirit, Intersex, Asexual
LMIC Low- to Middle-Income Countries
LTC Long-Term Care
LTCO Long-Term Care Ombudsman
MIPAA Madrid International Plan of Action on Ageing
NASOP National Association of State Long-Term Care Ombudsman
Programs
NCEA National Center on Elder Abuse
NEAIS National Elder Abuse Incidence Study
NICE National Initiative for the Care of the Elderly
OAA Older Americans Act
OAFEM Older Adult Financial Exploitation Measure
OAS Organization of American States
OBRA Omnibus Budget Reconciliation Act
OVW Ofce on Violence Against Women
PPHF Prevention and Public Health Fund
PHN Public Health Nurse
PTSD Posttraumatic Stress Disorder
Quirk-e The Queer Imaging & Riting Kollective for Elders
ROI Republic of Ireland
RRA Resident-to-Resident Aggression
RSA Resident-to-Staff Aggression
SDG Sustainable Development Goals
SN Self-Neglect
SN-37 Self-Neglect Assessment Measurement
SNSS Self-Neglect Severity Score
SSBG Social Services Block Grant
UK United Kingdom
US United States
USA United States of America
UN United Nations
UNDHR United Nations Declaration on Human Rights
CRPD Convention on the Rights of Persons with Disabilities
VAWA Violence Against Women Act
VOCA Victims of Crime Act
WHCoA White House Conference on Aging
WHO World Health Organization
yfAC Youth for a Change
Abbreviations
1© Springer Nature Switzerland AG 2020
A. Phelan (ed.), Advances in Elder Abuse Research, International Perspectives
on Aging 24, https://doi.org/10.1007/978-3-030-25093-5_1
Chapter 1
Introduction
AmandaPhelan
The genesis of this book began in an appreciation of how practice, legislation, policy
and research have expanded in relation to the topic of elder abuse. Elder abuse per-
meates all nations and prevalence statistics suggest one in six older people is affected
by some form of elder abuse with family members representing a high proportion of
abuse perpetrators (Yon et al. 2017). The growing volume of knowledge on this
topic has been in tandem with the increasing responsibility of the state in the private
domains of family, elder abuse being targeted as a public health issue and the con-
struction of elder abuse under the lens of human rights. An aging global population
presents a changing demographic landscape which not only requires but demands
reform in how populations live, are cared for and are responded to in society. What
is apparent is that safeguarding responses demand approaches that are enmeshed in
an ecological model, which acknowledges the intersectionality of marginalization;
this means the relinquishing of siloed contexts to older person safeguarding and the
authentic embracing of systems’ level prevention and intervention approaches.
1.1 Elder Abuse
Interpersonal violence is very common in contemporary society. There are many
different forms which include child welfare and protection, domestic violence (inti-
mate partner violence) and elder abuse. Other forms of interpersonal violence and
abuse include bullying, homicide, genocide, human trafcking and consequences of
forced displacement of populations (Ataullahjan etal. 2019).
A. Phelan (*)
National Centre for the Protection of Older People, School of Nursing, Midwifery & Health
Systems, University College Dublin, Beleld, Dublin, Ireland
e-mail: Amanda.phelan@ucd.ie
2
In this book, we concentrate on the domain of elder abuse. Elder abuse was rst
formally identied in the domain of medicine (Baker 1975; Burston 1975) but
instances of what we would now describe as the maltreatment of older people are
evident in the Bible, literature (Shakespeare’s King Lear is a classic example) as
well as various cultural and legislative practices (Phelan 2013). Early conceptual-
izations of elder abuse focused on physical abuse, while further scholarship
expanded understandings to include psychological abuse, nancial/material abuse,
neglect, and sexual abuse. As discussed earlier, prevalence studies demonstrate that
elder abuse is a global phenomenon which is impacted by issues such as culture,
gender and societal recognition. National prevalence studies in community settings
also indicate a wide variation rate from 2.2% in Ireland (Naughton etal. 2010) to
61.1% in Croatia (Ajdukovic etal. 2009) with a pooled prevalence from interna-
tional studies of 15.7% (Yon etal. 2017). The most common form of abuse in Yon
etal.’s (2017) systematic review and meta-analysis of 52 prevalence studies was
psychological abuse (11.65%), with nancial abuse at 6.8%, neglect at 4.8%, physi-
cal abuse at 2.65% and sexual abuse at 0.9%. The most common perpetrator in the
community setting is a family member, with a shared living accommodation being
a risk factor (WHO 2018). Other risk factors include the older person having a
physical or cognitive dependency. For example, studies on elder abuse related to
older people living with dementia show a signicantly higher prevalence of abuse in
both community settings and institutional settings (Fang and Yan 2018). However,
any general prevalence gures are likely to be impressionistic estimates (Bonnie
and Wallace 2003) and represent the iceberg theory, where we are only seeing a
partial representation of true gures (Phelan 2013). Some research has also been
undertaken to examine elder abuse in long-term care settings. In a 2018 systematic
review involving nine studies, psychological abuse was found to the most common
form of abuse (33.4%), with physical abuse at 14.1%, nancial abuse at 13.8%,
neglect at 11.6% and sexual abuse at 1.9% (Yon etal. 2018).
Another area of growing elder abuse scholarship relates to fraud and scams.
These types of abuse range from those acts perpetrated by known individuals
(family/friends) to those perpetrated by strangers. Financial abuse is particularly
signicant and is likely to be grossly underestimated. While family and ‘known’
individuals may apply strategies to have assets transferred through face to face
interaction, with the advent of a technological age, more sophisticated and targeted
methods have been applied to nancially exploit older people. For example, one
systematic review and meta-analysis estimated that 1in 18 cognitively intact older
people living in the community may be affected by scams (Burnes etal. 2017). This
includes the use of direct contact through the post, the telephone, social media
(Facebook, Twitter, Skype), phishing (email) or smishing (text). Such opportunistic
approaches by scammers are often based on the promise of a lottery win, the poten-
tial of a relationship (sweetheart scams) or fake charity donations.
It is recognized that, compared to other forms of family violence, elder abuse is
under-researched (Yon etal. 2018). Much of the theoreticalresearch on the topic is
based at the level between two individuals; the older person and the perpetrator.
Suchconstructions of dyadic abuse do not include institutional abuse or negative
A. Phelan
3
consequences due to structural issues in society, for example, genderized discrimination,
stereotypical ageist perspectives or ageist policy. Consequently, much work needs to
be undertaken to examine how elder abuse manifests at the level of community and
populations. Moreover, the bulk of scholarship is based on victims (Jackson 2016),
and this has been considered as a barrier to developing a range of response systems
(Wolfe 2003).
Challenges have presented in dening elder abuse and, as indicated, current
perspectives on the topic increasingly link elder abuse to human rights. This has led
to a concerted effort of replicating the success of the Convention on the Rights of
the Child (UN 1992) and the Convention on the Rights of Persons with Disability
(UN 2006) with debates in the United Nations on progressing a new bespoke
convention championed by the Open-Ended Working Group on Ageing for the
Purpose of Strengthening the Protection of the Human Rights of Older Persons.
While elder abuse is generally considered the domain of adult protective services
(mainly under the remit of health and social care services), there is an increasing
realization that responses need to be immersed in cohesive inter-sectorial, inter-
agency collaboration within and between services such as health and social care,
legal, forensic accountancy, nancial services, policing, policymakers, housing
departments, non-governmental organizations, independent advocates, and social
protection departments. While there are fundamental overlaps with interpersonal
violence such as issues of power and control, the taboo and closeted nature of abuse
as well as the context of elder abuse grown old (where abuse is continued to old age
rather than exclusive to old age) (Yon etal. 2014), there are also important differ-
ences. For example, ageist perceptions inuence how older people are viewed and
interacted with; the impact of paternalism is evident, particularly towards older
people with cognitive or physical challenges (Phelan 2013, 2018). Within society,
socially constructed dividing practices, such as age stratications, can ascribe
particular stereotypical views of age and underpin the ‘othering’ perspective; the
perception that those of another age group are not quite the same as ‘us’, and this
can lead to marginalization due to such taken for granted assumptions (Phelan
2018). Such marginalization has consequences, such as a higher tolerance to abuse
activities, thus, lessening recognition as well as the impetus to intervene (Shah and
Bradbury-Jones 2018; Phelan 2018).
Older people do not have the luxury of time in relation to recognition of the abuse,
nor the same amount of time to rebuild their lives. Entrenched values of stoicism
engendered over a lifetime, may mean a toleration of abuse and an internalization of
the stereotype embodiment theory (where the older person adopts ageist stereotypes,
believing the abuse is deserved) (Levy 2009) rather than help-seeking. Moreover,
having a dependency may mean a bartering in the context of accepting abuse in order
to prolong some physical and/or emotional contact, particularly with family. Older
people can have a reduced social contact network, making it more difcult to access
help, while simultaneously enabling a perpetrator to conceal the abuse. Thus, an
older person who appears to withdraw from social contact can be more easily
‘explained’ (through ill health for example) than a child who is prevented from going
to school or an adult who is absent from work or from community interactions.
1 Introduction
4
Recognizing elder abuse has also been complicated by a conation of the
indicators of abuse with physical and cognitive decline (Bonnie and Wallace
2003). There are a number of screening and assessment indexes which have
focused on increasing healthcare practitioners’ ability to detect elder abuse and
to initiate a referral. Some of the tools focus on an assessment of the older person
(e.g. Fulmer etal. 1984; Yaffe etal. 2008; Sengstock and Hwalek 1987), or the
caregiver (Reis and Nahmiash 1995; Wang etal. 2006) and there has been work
undertaken on more specic screening tools related to individual typologies of
abuse (Wang etal. 2007; Conrad etal. 2010). Some preliminary scrutiny has
been undertaken into the efcacy of interventions (O’Donnell etal. 2015, see
chapter by Phelan and O’Donnell), however this area requires additional exami-
nation to ensure adequate, appropriate and acceptable responses are available.
1.2 The Content ofThis Book
Within this book, the authors offer important insights into the topic of elder abuse.
Some chapters present the current state of knowledge in relation to an aspect of
elder abuse while other chapters provide country case studies on areas such as legisla-
tion and policy or advocacy and general awareness raising. This chapter, Chap. 1,
provides a broad background on the topic of elder abuse upon which to base reading
further chapters.
Chapter 2 by Phelan and Ayalon presents a debate on the impact of ageism on the
perpetration of abuse. Ageism is the stereotyping of older people which engenders
homogenous traits and can socially construct older people as different from other
age groups, thus, enabling different treatment, which can be paternalistic or of a
lesser standard. The chapter presents current understandings of both elder abuse and
ageism and also contextualizes how these two phenomena intersect within the
micro, meso and maco systems levels to create the potential for abuse and neglect.
Chapters 3 and 4 examine the issue of elder abuse in relation to legislation. In
Chap. 2, Phelan and Rickard Clarke present the orientation of safeguarding legisla-
tion towards person centred principles which are underpinned by a human rights
based approach and the centering of decision-making around the older person’s will,
preference, values and beliefs. Selected legal commentaries are presented to illustrate
how court decisions have orientated towards the views and perspectives of the older
person. In Chap. 4, Lowenstein and Doran use Israel as a case study to chart elder
abuse and neglect’s recognition and formal response systems (legislation and policy).
The chapter also provides a depth consideration of the trajectory within four legisla-
tive generations which have increasingly championed the empowerment of the older
person as well as early detection and intervention in elder abuse and neglect cases.
Chapter 5 (Teaster etal.) also examines how legislation and policy have expanded
to ensure a greater safeguarding impact on older people. The chapter specically exam-
ines the context of safeguarding in the United States and charts elder abuse as a social
justice issue. The authors trace the origins of public interest in safeguarding to the
A. Phelan
5
protective service units’ demonstration projects of the 1950s and presents the increas-
ing scope of legislation, policy and public funding in the prevention of and responses
to elder abuse. In particular, the Elder Justice Act from 2010 and the Elder Abuse
Prevention and Prosecution Act (2017) are presented as landmark advancements on
safeguarding in addition to further legislative protections. The chapter also offers a
review of international human rights based activities and age related declarations that
illuminate important directions in ensuring equitable and safe lives for older people.
Chapters 6 and 7 explore two categories of elder abuse which require some addi-
tional research focus and practice development. In Chap. 6, Malmedal discusses the
sexual abuse of older people. It is noted that within elder abuse, this form of abuse
is the least acknowledged as older people are subjected to ageist stereotypes of
being asexual. Sexual abuse of older people is dened as well as examining preva-
lence, risk factors, required responses and methods to enhance how society can
address this form of abuse.
In Chap. 7, Day traces the recognition, manifestations, risk factors and deni-
tions of self-neglect. Self-neglect is a complex issue which can be contextualized in
a continuum of severity (intentional or unintentional) encompassing cumulative
self-care decits and behaviors, which may include environmental squalor and
hoarding. Day presents ways of assessing the older person who is self-neglecting as
well as appraising how care can be managed, balancing ethical issues and safe-
guarding concerns.
One of the most insidious methods of elder abuse is that of nancial abuse as it
can be perpetrated without the knowledge of and remote to the older person. Chapters
8 and 9 focus on this subcategory of elder abuse. In Chap. 8, Phelan presents under-
standings and contexts related to the topic of nancial abuse. Financial abuse is very
complex and impacted by issues of family inheritance, relationships and the possible
need to rely on others to assist with nancial matters. The chapter argues that having
preventative protections decreases the risk of nancial abuse (for example, power of
attorney in place, money management programs) and having comprehensive, col-
laborative interagency responses can limit the perpetration and impact of nancial
abuse on older people. Most importantly, a cultural shift is needed related to the
assumption of control of assets and paternalism in nancial management as well as
the dispelling the myth that family have an automatic right to the assets of the older
person. Older people also need to be empowered to act against scams and fraud
through opportunistic contacts (door-stepping, telephone, post, internet, phishing,
vishing, smiching) which may prey on older people’s experience of loneliness, irra-
tional belief in the deception or simple naivety. Chapter 9 (O’Donnell) offers a way
to combat nancial abuse and describes an empowerment, co-design, educational
and information campaign to support older people to protect themselves. This work,
undertaken in Ireland, culminated in Keep Control, a multi-media educational and
information campaign developed by older people for older people. The three pillars
of the campaign are a website, a DVD and a resource or information pack. Through
these pillars, information and resources are provided within ve critical areas for
nancial self-protection: making a Will, implementing enduring powers of attorney,
opening joint accounts and authorizing signatures, making decisions at critical life
1 Introduction
6
events and protecting oneself on the doorstep. Keep Control adopts a strengths-
based perspective which celebrates, protects and fosters the agency of older people.
This understanding of empowerment describes a process by which people gain con-
trol over valued resources in order to make or inuence decisions which affect their
quality of life and well-being.
One of the high risk factors in elder abuse perpetration is that of cognitive impair-
ment. Cooper and Livingston (Chap. 10) offer critical insights into this context of
abuse pointing to the different dynamics within caregiving and the increased risk of
self-neglect in older peopleliving with dementia. For caregivers, the impact of care-
giving for an older person with dementia, particularly where behavior and psycho-
logical symptoms of dementia are present and where there is increasing hours of
caregiving, can lead to a context of abuse perpetration through dysfunctional care-
giving. The authors caution against paternalism, particularly where the older person
with dementia has decision-making capacity and decides to continue the association
with the alleged abuser. Here, the focus is on mitigating risk. Research undertaken
with caregivers (both formal and informal) of people living with dementia demon-
strates a much high prevalence of abuse. Ways of combatting the abuse of older
people living with dementia are discussed with a separate consideration of abuse of
people living with dementia in formal settings, such as nursing homes and abuse by
the family caregiver.
Chapters 11 and 12 discuss issues related to elder abuse in Lesbian, Gay, Bisexual
and Transgender (LGBT) communities and issues related to elder abuse and gender.
In Chap. 11, Gutman and colleagues reect on the unique and often overlooked
considerations in the domain of elder abuse related to LGBT where research and
practice have predominantly focused on mainstream, hetro-sexual populations. The
chapter highlights the variations of experience inherent in cultural differences and
social perspectives and emphasizes the imperative of engaging with LGBT people
to develop understandings and appropriate responses. Central to understanding is an
intersectional approach which appreciates the unique interface of age, gender and
sexuality of older LGBT people.
Penhale, in Chap. 12, provides a contextual backdrop to elder abuse and then
examines the pivotal issues impacting on gender experiences of abuse. The chapter
considers the issue of vulnerability and recognizes that it is predominately linked to
both situational and circumstantial factors and is conceptualized as a risk factor in
elder abuse and, similar to points made by Gutman and colleagues, points to the
intersectionality of age, disability and gender. In addressing a gender-based response
to elder abuse, the important issue of power relations is crucial to address. Further
scholarship in the domain of theoretical advancement needs to acknowledge the
diverse experiences and contextual factors which are impacted by gender. In doing
so, the voices of older women and men need tobe incorporated into elder abuse
research to identify the differences in their abuse experiences. In this way, bespoke
interventions and model projects which utilize empowerment and rights based
approaches can be developed and evaluated for impact.
Chapter 13 examines a relatively new area of elder abuse scholarship, that of
resident to resident aggression, occurring in nursing homes. Resident to resident
aggression is constituted by categories which include physical, sexual, psychologi-
A. Phelan
7
cal, nancial abuse, humiliating behavior and social exclusion; this type of abuse
has a general prevalence of approximately 20%. Resident to resident aggression can
have a signicant impact on the health and welfare of older residents. Goergen and
colleagues point to dementia as one inuencing factorin abuse perpetration, but for
this population, resident to resident aggression can be aggravated by pain and
depression. The chapter presents a recent mixed method study on resident to resi-
dent aggression in Germany. Findings demonstrate that this form of abuse is not
unusual in nursing homes and that it is generally observed in older residents’ com-
mon living areas. Risk factors include individual factors, interpersonal dynamics as
well as the physical and social characteristics of the nursing home. The chapter
concludes with recommendations on how to address resident to resident aggression,
such as training and education for staff and attention to the spatial environment.
In Chap. 14, Phelan and O’Donnell present ndings based on a study undertaken
in the National Centre for the Protection of Older People, University College
Dublin, Ireland (O’Donnell et al. 2015). The study applied a socio-ecological
approach to exam interventions for elder abuse. Following an integrated review of
the literature, 98 interventions were examined and identied within micro, meso,
exo and macro systems. The papers were also categorized into either descriptive or
experimental studies/papers. Findings demonstrated that there is a relative paucity
in the evaluation of elder abuse interventions and that additional work is required,
particularly, related to larger population based studies. In addition, comparison of
studies is limited by issues of methodological approaches and structural conditions
within each jurisdiction.
Chapter 15, authored by Yon and colleagues,contextualizes elder abuse as a seri-
ous public health problem which has dire consequences for the victims, their fami-
lies and society. In Europe, it is estimated that 15.4% of older adults in the community
and up to 33% of older adults in institutional settings experienced some form of
abuse in the past year. The chapter summarizes the risk factors as well as prevention
efforts in responding toelder abuse. Moreover, the chapter examines three broad
questions: (a) how can the awareness among health policy on the extent of the prob-
lem of elder abuse be raised; (b) what prevention programs have countries imple-
mented at national levels; and (c) to which extent have countries been developing
national action plans to coordinate action against elder abuse? The chapter con-
cludes with reections on a way forward with a series of integrated actions to
address elder abuse.
In Chaps. 16 and 17, the authors trace the impact of non-government organiza-
tions on safeguarding older adults using the case examples of Serbia and Ireland. In
Chap. 16, Todorovic and Vracevic present the increasing focus on the abuse of older
adults in Serbia through research, awareness raising and advocacy by the Red Cross
organization. Three Serbian seminal research studies have identied the issues in
family relationships, response organizations’ case management and legal gaps
which disempower older people and create challenges in safeguarding. The work
undertaken has had a particular focus on the promotion of a human rights agenda
with a concurrent involvement of the Red Cross at an international level. In Chap.
17, Taylor examines the role of independent advocacy in safeguarding vulnerable
adults again highlighting the need to explicitly benchmark the treatment of older
1 Introduction
8
people with human rights. Using Ireland as a case example, common issues which
can limit rights and limit choices for older people are discussed. These include fund-
ing inequities between nursing home care and home care, misunderstandings on the
meaning of ‘next of kin’ as well as the phasing out of the wardship system of legal
decision making capacity management, and issues related to medical models of
care. Taylor argues for an increased professional and public awareness of abuse as
well as an integrated safeguarding system (with standards and training), which
places a greater emphasis on strategy and tactics, rather than resources as well as
accommodating various levels of advocacy to enable person centredness.
In reviewing all 17 chapters in this book, it is hoped that a broad and inclusive
consideration of the topic of elder abuse is provided. However, this book represents
aspects of scholarship pertaining to elder abuse at this point in time. As the knowl-
edge base expands and new insights are constructed, better conceptualizations and
insights will be produced. Nonetheless, from contemporary understandings, what
has emerged is the need to have sustainable responses that are effective and efcient
yet exible and person centred to adapt to the particularities of the abuse case. An
essential component of such interventions is the involvement of the older person as
much as possible so that interventions and responses integrate the voice of the older
person and privileges their will, preference, values and beliefs. This can present an
uncomfortable position for those involved in safeguarding, whose judgment of risk
precludes the facilitation of acceptable risk and the identication of strategies to
reduce or mitigate such risk. What is needed to enhance professional decision-
making is a rights based approach incorporating the authentic involvement of the
older person as much as possible. Within intervention systems, having timely
responses, specialist multi-disciplinary teams, forensic centers, enhancing legal
processes and elder death review teams are fundamental. As with all interventions,
their evaluation in terms of acceptability and outcomes is essential and should com-
prise the involvement of all stakeholders. Only then can we provide comprehensive
and appropriate responses to the societal challenge of elder abuse.
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1 Introduction
11© Springer Nature Switzerland AG 2020
A. Phelan (ed.), Advances in Elder Abuse Research, International Perspectives
on Aging 24, https://doi.org/10.1007/978-3-030-25093-5_2
Chapter 2
The Intersection ofAgeism andElder
Abuse
AmandaPhelan andLiatAyalon
2.1 Introduction
Within the twenty rst century, there is a social transformation with the global
success of longevity as populations’ age. The demographic transition points to
both an increasing life expectancy and a greater proportion of older people. For
example, the average global life expectancy has more than doubled since 1900
(Roser 2018) with life expectancy at birth being 72years in 2016 (WHO 2018) as
compared to just 53years in 1960 (World Bank 2018). Projected gures point to a
doubling of people over 60years from 962 million in 2017 to 2.1 billion in 2050
and 3.1 billion in 2100 (United Nations 2017). While this represents a major suc-
cess in human longevity, the extension in quantity of years demands a concurrent
optimization of quality of life (Phelan 2018), particularly related to the ability to
live a life free from abuse.
Abuse occurs when there is a failure to respect the individual humanity of the
older person. Age is an important dimension of social status and is intrinsically
linked to culture and socio-historical experiences (Roscigno etal. 2007). Nelson
(2005) recognizes the implicit human propensity of categorization within areas
such as gender, race and age which can result in stereotyping and prejudicial
treatment. Ageism has been described as the systematic discriminatory treatment
of people because of their age and elder abuse represents the individual experi-
ence of maltreatment. Elder abuse refers to how older people can be treated in a
negative way which can be manifested in physical abuse, psychological abuse,
A. Phelan (*)
National Centre for the Protection of Older People, School of Nursing, Midwifery & Health
Systems, University College Dublin, Beleld, Dublin, Ireland
e-mail: Amanda.phelan@ucd.ie
L. Ayalon
Faculty of Social Sciences, Gabi and Louis Weisfeld School of Social Work, Bar-Ilan
University, Ramat Gan, Israel
12
material/nancial abuse, sexual abuse and neglect. In addition, Harbison (2016:
284) argues that ageism is inherent in many states’ political discourses of older
people as ‘an unaffordable social and economic burden’ and this is intricately
linked to the conditions enabling abuse. In this chapter, we consider how elder
abuse and ageism, as a categorization of social perception (Nelson 2005), inter-
sect. We examine how ageism can be a permessor, (a factor which enables mal-
treatment to occur) and then discuss how ageism intersects with elder abuse at the
macro-level, meso-level and micro-level.
2.2 Elder Abuse
Elder abuse was the last form of family violence to be formally recognized. Similar
to child protection (Kempe etal. 1962), its recognition emerged within the eld of
medicine (Baker 1975; Burston 1975), while domestic violence emerged in the late
1960s from a feminist discourse, recognizing the power imbalance within gender
relations. Elder abuse is dened by the WHO (2008: 6) as:
…a single or repeated act or lack of appropriate action occurring within any relationship
where there is an expectation of trust that causes harm or distress to an older person.
While this denition has some impetus, there are inherent challenges. The deni-
tion constructs abuse within a relationship as well as inferring that the maltreatment
must have an impact (harm or distress) to constitute abuse. As such, abuse is then
dened by who the perpetrator is and necessitates some consequential negative
experience, rather than abuse as an independent act in itself. More recently, deni-
tions have sought to be more inclusive and a particular focus on benchmarking
abuse to human and civil rights has been apparent (WGEA 2002; WHO 2002;
HIQA 2016; Purser etal. 2017). Denitions are inuenced by issues such as inter-
personal relationships, a lack of discrimination between normal and abusive inter-
personal conict and can also be limited by scant attention towards ageism, culture
and social circumstances (Mowlam etal. 2007; Phelan 2013).
Another factor in understanding elder abuse is that denitions can differ accord-
ing to professional discourses; for example, legal, case management and research
denitions can vary. Legal denitions draw on abuse due to a crime being commit-
ted, case management denitions relate to making clinical decisions based on eligi-
bility to services and the provision of information evaluating the context while
research denitions guide the parameters of a study (Phelan 2010).
Elder abuse is perpetrated in many ways, through physical abuse, psychologi-
cal abuse, material/nancial abuse, sexual abuse and neglect. There is some debate
on the inclusion of self-neglect as a category of elder abuse. For example, the
Adult Protective Services in the United States recognizes self-neglect as a form of
elder abuse, yet, up until 2014, Ireland’s elder abuse policy (WGEA 2002) speci-
cally excluded self-neglect, although due to the volume of self-neglect referrals,
the health service accepted serious cases of self-neglect from the late 2000s.
A. Phelan and L. Ayalon
13
Moreover, there is a difference in understandings of categories of elder abuse.
Studies examining how older people themselves construct elder abuse differ from
the traditional categories cited above and point to perspectives imbued with cul-
tural representation as well as the individual’s own personal ageing experience
and values (Mowlam etal. 2007; Phelan 2010). For example, older people have
pointed to categories based on abandonment, social isolation and social exclusion,
human, medical and legal rights, decision-making abuses or a lack of respect
(WHO and INPEA 2002). In a Swedish study, Erlingsson etal. (2005) facilitated
focus groups with older people to generate understandings of elder abuse. Findings
pointed to a more sociological level perception of elder abuse with participants
observing a changing society with poor government priorities, understafng in
services important to support older people (law and health), negative attitudes to
older people, a lack of staff with expertise in aged care, unstable family units and
specic perpetrator factors. Taylor etal. (2014) argue that prioritizing older peo-
ple’s subjective experiences, in terms of dening what elder abuse is, enables a
more comprehensive understanding and contributes to the prevention of ageism.
Theories of elder abuse frequently focus on the dyadic relationship between the
older person and the perpetrator(s) and can reect ageist perspectives of depen-
dency and vulnerability. These include dyadic frameworks namely the caregiver
stress/situational theory, the social exchange theory, the domestic violence theory,
the psychopathology of the abuser theory, the symbolic interaction theory and the
social learning/intergenerational abuse theory. These are briey outlined below. For
additional information see Phelan (2013):
• Caregiver stress/situational theory: This theory suggests abuse happens as the
challenges of caregiving increase. The incremental stress experienced by the
caregiver provides the context for abuse occurring.
• Social exchange theory: Relationships are built on ‘give and take’ where there
are mutual benets for individuals. As an older person ages, dependency may
increase and the ‘demands’ on the caregiver may grow, while the benets of the
relationship are considered diminished. This imbalance may create a conict
environment as well as resentment and anger due to the reduced rewards within
the relationship. Attempts to redress this imbalance may be constituted by threats
of abuse or actual abuse. This theory assumes that relationships are based on
maximizing benets and minimizing costs In addition, neglect may occur due to
ignoring the increased care demands and consequently, reciprocity becomes
eroded (Phelan 2013).
• Domestic violence theory: This theory may in some cases, simply reect domes-
tic violence grown old. Elder abuse statistics frequently show that women are
more likely to be abused than men (Naughton et al. 2010; WHO 2018).
Consequently, this theory draws on feminist arguments of power imbalances
related to gender inequality, emphasizing the social and structural conditions that
may precipitate abuse (Yllo 2005).
• Psychopathology of the abuser theory: This theory considers that there are some
innate characteristics the abuser holds which predispose to abuse. For example, the
2 The Intersection ofAgeism andElder Abuse
14
abuser may have a mental health challenge, intellectual disability or a personality
disorder, which prevents him/her from engaging in the care expectations of the
relationship with the older person and these circumstances can predispose to an
abuse situation (Norris et al. 2013). Equally, the abuser may have a substance
abuse or alcohol problem which leads to distorted thinking and a need to fulll
their addiction. For example, the need to fulll the addiction may lead to nan-
cially abusing the older person, psychological abuse or physical violence.
• Symbolic interaction theory: Drawing on the work of George Herbert Mead,
symbolic interactionism is based on how we interact and mediate our interac-
tions with others. Culture has a major inuence on symbolic interactionism,
however, the individual relationship may be underpinned by the abuser mediat-
ing behaviours by how successful they may be. This is particularly seen in the
context of families ageing and roles changing, creating tension within families.
• Social learning/intergenerational abuse theory: This theory is based on the
premise that behavior is learned. Thus, abuse is a normal and acceptable way of
addressing conict which may be transmitted from generation to generation and
may occur within relationships at any age.
Other more macro-perspective theories of elder abuse such as the political econ-
omy theory and the ecological theory and can also reect ageism. For example, the
politico-economic theory addresses how older people are marginalized in society,
which reects an ageist perspective (Wolf 2003). Policy may dictate that older peo-
ple are required to leave the workforce at a particular age and this can be com-
pounded by losing roles and reducing independence, which may lead to elder abuse
(Abolfathi-Momtaz etal. 2013). Retirement, as a social practice, has been linked to
ageism (McDonald 2013).
The ecological theory, which is elaborated in this chapter, draws on the work on
Bronfenbrenner (1979) and centres on systems’ levels from the micro-system to the
macro-system (also see Phelan and O’Donnell’s chapter in this book). All of us are
embedded in complex systems which range from our direct environment (i.e. fam-
ily) to national and international inuences on our lives (legislation, human rights).
The impact of ageism as a contributory factor in elder abuse perpetration has
been conceptualized under an ecological lens in recent studies (Norris etal. 2013;
O’Donnell etal. 2015; Dow etal. 2018). Within all system levels, ageist practices
can lead to marginalization, constructing older people as ‘others’ (Dominelli 2003;
Walsh etal. 2010) and not being quite the same as younger generations, enabling
paternalistic treatment.
Norris etal. (2013: 52) suggests that the conceptualization of elder abuse requires
a particular critical ecological examination, which demands an appreciation of mul-
tiple inuencing factors (including ageism) which give rise to the conditions of
possibility of elder abuse:
Further exploration [of elder abuse] is needed on several fronts—the intersection between
ageism with patriarchy, capitalism, and familialism and the way in which ageism transcends
gender; the development of frameworks that position older adult abuse as a collective social
program…
A. Phelan and L. Ayalon
15
Thus, it is this crucial inter-sectionality between ageism and abuse which con-
tributes to the conditions of possibility of abuse.
2.3 Ageism at theMacro Level
Ageism is dened by the World Health Organization as the way we think, feel and
act towards people because of their age (Ofcer and de la Fuente-Núñez 2018).
Ageism can be both positive and negative and can be directed towards people of all
age groups (Ofcer and de la Fuente-Núñez 2018). However, the majority of research
to date has focused on ageism as the negative construction of old age. Ageism can be
both explicit and implicit and can be directed towards others but also towards oneself
(Ayalon and Tesch-Römer 2017). Ageism can occur at the individual level, interper-
sonal level and at the societal level (Ayalon and Tesch-Römer 2018).
Ageism is manifested in laws and legislations as well as in what these laws and
legislations target or refrain from targeting. In 1948, the United Nations (UN)
General Assembly adopted a Universal Declaration of Human Rights, emphasizing
the fact that all individuals have the same rights. Yet, seven decades later, age is still
not an explicit part of a UN declaration1. Direct associations between human rights
and elder abuse have been noted (Phelan 2008; Biggs and Haapala 2013). Human
rights are positioned as benchmarking standards against which human experience
can be viewed. Equally, a human rights agenda points to the legal obligations of
states to address and remediate discrimination (Sepúlveda and Nyst 2012). However,
Biggs and Haapala (2013) caution against an unproblematic and uncritical link
between ageism, human rights and abuse, suggesting a critical assessment of the
quality of the boundary between society, self and other needs. Consequently, issues
such as adult to adult relationships, autonomy and social expectations need to be
considered in the inherent wider social context (Biggs and Haapala 2013).
Much of the discussion of old age and ageing at the European level, for instance,
has been colored by ageist attitudes, describing older adults as a challenge to soci-
ety (Georgantzi 2018). Similar perspectives have been noted in other regions, for
example, Canada (Harbison 2016). Age remains the only basis on which discrimi-
nation at the European level is still considered legitimate (Georgantzi 2018).
Moreover, the use of terms such as the dependency ratio as a measure of older
people’s limited value to society also results in equating old age with being a burden
to or redundant in society (Georgantzi 2018). It is expected that this view of old age
and the legitimization of discrimination based on age reduces the awareness ofelder
abuse and neglect and possibly makes elder abuse more permissive for policy mak-
ers and legislators. This perspective is supported by Angus and Reeves (2006) who
suggest that ageism positions older people as inferior and elder abuse can be tacitly
tolerated (McDonald 2018). Thus, ageist perspectives within the macro-context of
society are operationalized through individual experience. For example, in the case
1 http://www.helpage.org/what-we-do/rights/towards-a-convention-on-the-rights-of-older-people/
2 The Intersection ofAgeism andElder Abuse
16
of nancial abuse, many studies point to the cultural sense of entitlement of younger
generations to assume ownership, unproblematically, of the assets of older people;
the perspective being the older person doesn’t need the money, which is to be inher-
ited by younger generation in any case. Equally, if abuse of older people as victims
of crime enters the legal system, there is also evidence of ageism in terms of less
favorable access to procedural justice, in this context, the legal system failing to
accommodate for older people’s distinct needs, which subsequently negatively
impact on successful crime outcomes (Brown and Faith 2018).
Within many countries, if an older person’s independence becomes challenged
due to cognitive or physical decline, admission to long-term nursing home care
becomes necessary. However, from a cultural perspective, admission to a nursing
home can itself be seen as abusive. In China, for example, the Confucian principle
of lial piety translates to the expectation that children will look after their older
parents (Kim etal. 2015). However, there appears to be a resistance to such cultural
values as it is noted that there is growing resentment in taking on the responsibilities
of caregiving, as traditional values of respect and honoring elders decreases
(Compernolle 2015).
2.4 Ageism at theMeso Level
Oftentimes, ageism occurs in social interactions between older adults and the gen-
eral public (Kite etal. 2005), among older adults (Ayalon 2015) and between older
adults and various professionals, including health and long term care providers
(Kane and Kane 2005; Wyman etal. 2018). Ageism can potentially incite or inten-
sify the occurrence of elder abuse and neglect in any of these instances. When inter-
acting with others, a view of older adults as a burden to society, as slow to respond
and as irrelevant might result in their exclusion from the public sphere (Clarke and
Grifn 2008; Minichiello et al. 2000). Under such circumstances, ageism is more
likely to be unnoticed or even accepted.
Many studies have pointed to ageism in healthcare manifested through interac-
tions, policy and organizational cultures (São José etal. 2017; Ben-Harush et al.
2017) and ageism has been linked to reduced care quality (Wyman et al. 2018;
Bodner etal. 2018). Within healthcare professionals, it has been demonstrated that
there is a preference to work with younger generations (Kane 2004; Lee etal. 2018).
Professionals may hold more accepting views towards abuse of older people.
For instance, an experimental study, which relied on a case vignette, has found
that social workers were more likely to identify intimate partner violence when
the victim was a younger woman than when the victim was an older woman. In
addition, they were more willing to support and treat the younger person
(Yechezkel and Ayalon 2013). A study by Kane etal. (2010) demonstrated the
impact of age on scenarios of domestic violence in couples aged between 30 and
75years. Findings demonstrated a lesser appreciation of the severity of abuse in
A. Phelan and L. Ayalon
17
the older couple. The authors point to challenging stereotypical assumptions that
older couples were generally in a harmonious relationship and happy, thus raising
awareness that intimate partner violence is ageless. Other forms of ageism by
professionals might be instigated by the thought that older adults are asexual
(Gewirtz-Meydan et al. 2018) and thus, are not subject to sexual abuse, for
instance. Moreover, thinking that older adults are incapable of managing their
own affairs might result in putting great power in the hands of others, who could
potentially be abusive towards the older adult. This might also result in reducing
older adults’ autonomy (Tampi etal. 2018).
Ageism has been noted in studies based on residential care (Dobbs etal. 2008)
and both Harris (2005) and Jönson (2016) make an overt link between ageism and
abuse in nursing homes suggesting that ageist attitudes are a factor in abuse
perpetration.
Prevalence studies of elder abuse demonstrate that abuse does occur in nursing
homes. While many of these studies focus on examining the categories of abuse
perpetrated in dyadic interactions, there is little research focusing on ageism and
institutional abuse, although care scandal reports and regulatory body reports dem-
onstrate activities that would be considered abusive (Francis 2013; HIQA 2018).
Institutional abuse may be dened as:
…the mistreatment of people brought about by poor or inadequate care or support, or sys-
tematic poor practice that affects the whole care setting. It occurs when the individual’s
wishes and needs are sacriced for the smooth running of a group, service or organization.
(Harrow Council n.d.)
Begley and Matthews (2010) link institutional abuse to ageist assumptions, stat-
ing that human rights may be eroded through such stereotypical negative views of
older people. Some studies have demonstrated indicators of ageism, such as infan-
tilization of older people, as being associated with abuse (Pillemer and Moore 1989;
Bužgová and Ivanová 2009), with almost 11% of staff in an Irish study indicating
that older people were like children and needed to be disciplined from time to time
(Drennan etal. 2012). In a qualitative study on ageism and elder neglect in long
term care facilities, Band-Winterstein (2015: 5) describes the link between ageism
and elder abuse as the ‘twilight zone’. Two themes were identied which illuminate
ageism in care delivery. Firstly, the tacit normalization of neglect as older people are
rendered transparent in everyday routines leading to the objectication of the older
person within task orientation and economics rather than person centred care deliv-
ery. Secondly, the institutional approach minimizes the value of older people and
there is a growing importance in bureaucratic activities as opposed to evaluating
person centred outcomes. Both factors can result in ageist stereotypes, for example,
being non-productive, dependent or asexual (Band-Winterstein 2015). Yet, a third
theme pointed to staff’s conscious knowledge of such poor systems of care and
participants suggested ways to combat ‘neglect in an ageist reality’ (Band-
Winterstein 2015: 9). These included increased multi-disciplinary input, reective
practice which priorities person centeredness as well as engaging in overt conversa-
tions on ageist practices.
2 The Intersection ofAgeism andElder Abuse
18
2.5 Ageism at theMicro Level
Research has consistently shown that older adults internalize ageist messages
throughout their lives (Levy 2001, 2009). This results in some older people thinking
that, because they are aged, they are slow, useless, over the hill or a burden to soci-
ety (Minichiello etal. 2000). Internalizing these negative messages might result in
older adults being more reluctant to report events of abuse, as they already feel
powerless and unnoticed in society. Moreover, older adults might be more likely to
accept abusive experiences simply because of their negative self-evaluation. Thus,
abuse may be tolerated or even unrecognized because of learned and accepted
dependency positioning of older people in society. Within care environments, there
can be a tendency to assume a paternalistic approach in the context of decision-
making. This renders the older person ‘voiceless’ in his/her care and denies self-
determination and autonomy, constituting an ageist agenda (Ward 2000; Doyle
2014). This is a particular issue in relation to decision making capacity, where fami-
lies and/or healthcare staff can assume paternalistic positions or place undue inu-
ence on the older person based on age. Consequently, it is important that healthcare
and social care professionals understand how to support individual human rights
within care delivery and within society itself, so that rights are authentically experi-
enced and enjoyed by all human beings regardless of age, decision-making capacity
or paternalism from professionals or family.
2.6 Conclusion
Prevalence studies globally demonstrate that elder abuse is a challenge in many
societies. In this chapter, we have considered the intersection of elder abuse and
ageism drawing on an ecological, systems based approach. Ageism presents as a
systematic stereotypical approach to older people manifested in behaviors, prac-
tices, attitudes and discourses (interpersonal and policy) within everyday life. In
2005, Nelson observed a link between ageism and elder abuse, arguing that ageist
attitudes position older people as second-class citizens and enabled a higher degree
of tolerance of neglect and exploitation. More recently, ageism as a contributory
factor to elder abuse was identied (Norris etal. 2013; Dow etal. 2018), with earlier
commentators suggesting that ageism impacts the understanding of elder abuse
(Gelles 1997) as well as impacting formal reporting of such maltreatment (Podnieks
2006). While some work has been undertaken into the oppression of older people
using the lens of ageism and elder abuse (McDonald and Sharma 2011; Brownell
and Kelly 2013; Harbison 2016), a recent review of contributory factors points to
the need for additional supporting evidence (Pillemer etal. 2016). Thus, more work
is essential to understand the inherent power and culture dynamics as they are mani-
fested within ecological systems. Imbalances in power can be due to multiple forms
of oppression, including ageism, sexism, racism, poverty, disability, sexual
A. Phelan and L. Ayalon
19
orientation which, either individually or combined, lead to heightened risk for abuse
perpetration (Walsh etal. 2010). Consequently, for effective preventative and inter-
vention responses to elder abuse, the conditions of possibility, which includes age-
ism, need to be addressed within multiple environmental systems.
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A. Phelan (ed.), Advances in Elder Abuse Research, International Perspectives
on Aging 24, https://doi.org/10.1007/978-3-030-25093-5_3
Chapter 3
Person Centred Approaches inCapacity
Legislation
AmandaPhelan andPatriciaRickard-Clarke
3.1 Introduction
A major issue within safeguarding is upholding an individual’s rights particularly
related to free choice and making decisions autonomously. In this chapter, the con-
cept of person centredness is presented and its relationship and impact on capacity
legislation. Person centredness has emerged in the discursive space of health but its
core principles are intrinsically linked to the wider concepts of rights, autonomy and
self-determination. Where there are decision-making challenges, many states have
progressed legislative protection to preserve and facilitate an individual’s will, pref-
erence, values and beliefs. This represents a more integrated and cross sectional
approach to person centred principles and concurs with a rights based approach.
Rights may be viewed as encompassing both human rights, as detailed in the United
Nations Declaration on Human Rights (UN 1948) and the United Nations Convention
on the Rights of Persons with Disabilities (UN 2006) and citizenship rights which
prescribe the state-citizen relationship (Phelan 2012). Both human rights and citizen
rights are generally reected in legislation representing a state’s explicit expecta-
tions in terms of responsibilities, entitlements and duties both towards citizens and
expected of citizens. Accordingly, current understandings of decision-making
capacity are examined together with recent legal commentaries in the Ireland and
the United Kingdom reecting a person centred approach.
A. Phelan (*)
National Centre for the Protection of Older People, School of Nursing,
Midwifery & Health Systems, University College Dublin, Beleld, Dublin, Ireland
e-mail: Amanda.phelan@ucd.ie
P. Rickard-Clarke
National Safeguarding Committee, Dublin, Ireland
24
3.2 Person Centred Care
The origins of the term ‘person centred’ lies within the eld of psycho-therapeutics
(Brooker 2003). Rogers (1951), an American psychologist, applied a humanistic
approach using the term client centred care, which was, over the years, replaced by
the term person centred care. Rogers (1980) proposed that core conditions were
necessary to enable human growth and ourishing and relationships needed to be
underpinned by congruence (genuineness), empathy and unconditional positive
regard. While such concepts are fundamental in person centred care, more contem-
porary understandings can be traced to Tom Kitwood (1997), who, drawing on the
work of Burber (1937), emphasized the essential nature of recognizing personhood
in each individual regardless of cognitive or physical ability. As such personhood is
an inherent essence of humanness and is commonly viewed as ‘the attributes pos-
sessed by human beings that make them a person’ (Dewing 2008: 3).
The challenge of ascribing a particular status or applying attributes for person-
hood has been noted (Dewing 2008; McCormack and McCance 2010). Personhood
has been linked with traits such as rationality and thinking. For example, Decartes,
a seventeenth century philosopher, dened a person through his famous idiom ‘I
think therefore I am’, linking the meaning of being a person to the rationale mind.
This suggests the diminishing of personhood when capacity and competence are
challenged and being unheard and unrecognized is akin to ‘absolute death’ (Bakhtin
1984). Such benchmarking, typical of empirical functionalism, can lead to a hierar-
chy and exclusion of individuals who do not meet the required ‘criteria’. Moreover,
some of these common ‘dening’ attributes are not unique to humans (self-
determination, language, thought, memory), but may be observed in animals, blur-
ring understandings of personhood (McCormack and McCance 2010). Terms such
as ‘loss of self’, associated with the progression of dementia related diseases, also
tacitly suggest a loss of personhood where personhood is solely related to cognitive
function (Buchanan and Brock 1990; Liebing 2008). Thus, the danger of an empiri-
cal functionalist approach, typical of the use of dening attributes to personhood, is
that there may be consequences such as being treated in a lesser and unequal way
(Fu-Chang Tsai 2009). Rather, personhood is dynamic, in continual development
and ux, taking account of temporality and corporeality (Dewing 2008).
Consequently, taking an ontological personalism approach is more helpful, infer-
ring that all human beings are persons, regardless of attributes (Nelson 2009).
Kitwood (1997: 8) further contends that personhood is only actualized through
our interactions with others within the context of relationships, requiring ‘recogni-
tion, respect and trust’. It may be constructed as a status afforded within authentic
interpersonal relationships (Penrod etal. 2007; Nolan etal. 2004). These descrip-
tions have been subject to some critique, as they imply personhood exists within
relationships, rather than a unique way of ‘being’. Consequently, McCormack
(2004) argues that ‘being’ is central to personhood and has four dimensions which
represent each individual’s life world: being in relation, being in a social world,
being in place and being with self.
A. Phelan and P. Rickard-Clarke
25
The aim of person centred care is prioritizing the individual’s authentic wishes,
appreciating their uniqueness, respecting rights, building mutual trust and the
engagement in therapeutic relationships (McCormack and McCance 2017). Person
centred care is underpinned by the fundamental equality and self-determination of
human beings and the recognition and facilitation of what matters to that person
(Liebing 2008). As such, people are entitled to make autonomous, informed choices
and should be enabled and supported to participate in their care/lives at the level
they desire (Ganzini etal. 2004; WHO 2015). Within health and social care, this
represents a move from traditional bio-medical models to psycho-social models
which transcend the narrow focus on the medical condition and tasks to the appre-
ciation of the totality of the person and the context of their life experience, their
personal values, preferences and life world, countering paternalism. Person centred-
ness is essentially focused on putting people at the heart of care delivery where they
experience positive benets (WHO 2015). However, this requires a move beyond
mere rhetoric to the transformation of care cultures enabling human ourishing
(Richards etal. 2015).
Globally, there is a growing focus on person centred approaches within the con-
text of health care reform (Harding etal. 2015; McCormack and McCance 2017).
Person centred care has also been framed beyond the individual dyadic relationship
to include a wider context (McCormack and McCance 2017; Harding etal. 2015).
Further work by Kitwood and others point to the social and relational environment
within which people with dementia live and suggest that a malignant social psy-
chology fundamentally erodes their experience of personhood (Kitwood 1997;
Todres etal. 2009).
In particular, McCormack and McCance’s (2010, 2017) framework promotes the
essential need for person centred cultures which require particular prerequisites of
the healthcare professional, the care environment, the processes involved in deliver-
ing care and the need to evaluate outcomes. Work within person centred care has
extended to person centred co-ordinated care (Phelan etal. 2017) and personaliza-
tion agendas in healthcare (Manthrope and Samsi 2016) typied by consumer
directed care (Phelan etal. 2018). Within the regulation of health, a person centred
approach has been increasingly evident. For example, within the Irish Health and
Information Authority (established in 2007) standards, policy documents are replete
the need for care environments to centralize the individual’s will and preference
though person centred approaches.
3.3 Decision-Making Capacity
As indicated in the discussion on personhood, maintaining a person’s will and pref-
erence is paramount, regardless of cognition challenges or physical appearance.
However, decision-making is based on capacity. Decision-making capacity may be
described as the ability of an individual to exercise self-determination and commu-
nicate this to others (Spike 2017). All people have a right to make an uninuenced
3 Person Centred Approaches inCapacity Legislation
26
and informed decision and this is fundamental to quality of life. Even when
decision- making capacity is in question, people still value being involved or having
their preferences authentically and genuinely represented (Featherstonhaugh etal.
2016). Decision-making is afforded legal status when consent is formalised (Walter
et al. 2018). Flynn and Arstein-Kerslake (2014) argue that legal personhood is
linked to the possession of decision-making capacity, where cognition and auton-
omy are intrinsically prized. Similar arguments are posited by Post (2006) who
suggests that the loss of an individual’s cognition translates to a cultural diminish-
ing of their personhood. This leads to a situation of a social positioning of vulner-
ability and a consequent perception of a need to overprotect which, more insidiously,
tacitly sanctions paternalism. Within person centred care, the ‘voice’ of the person
is prioritized, however, practically, this often depends on the judgment of the health-
care professional that the person has decision-making capacity (Ganzini et al.
2004). Both Ganzini etal. (2004) and Spike (2017) emphasize the lack of distinc-
tion in healthcare practice related to decision-making capacity and competence.
Although conceptually interlinked, decision-making capacity is a clinical based
assessment of the ability of a person to make a particular decision, while compe-
tency is a legal appraisal of the person’s ability to make decisions in general (Ganzini
etal. 2004). While decision-making capacity challenges require clinicians to exam-
ine if there is a representative decision maker legally appointed, courts deliberate on
competency and can appoint a representative decision maker.
Historically, in many countries, legislation has assumed a paternalistic approach
(see Lowenstein and Doran in this book). For example, the Lunacy Regulation Act
(Irish Statute Book1871) in Ireland enabled a system of wardship for those deemed
to be incapacitated. Most often, the foundations for granting wardship were
entrenched in a status approach to capacity, based on medical cognitive testing
rather than actual ability to make individual, informed decisions. Indeed, Spike
(2017) observes that challenges to decision-making capacity often invoke (errone-
ously) a psychiatric consultation and many of the assessments are based on tests
developed for dementia rather than decision-making capacity and are comprised of
the various mental status exams. Spike (2017) further argues that the misuse of this
test can lead to false conclusions. Moreover, the stimulus to suspect decision-
making capacity challenges could simply be the individual having a different opin-
ion to the doctor/nurse. Conversely, there can also be a myth that agreeing with
healthcare practitioners means there is no need for decision-making capacity assess-
ment although informed consent may, in fact, be absent (Ganzini etal. 2004).
Assessing capacity presents a moral, legal and ethical challenge in health, legal
and social care environments (Pennington etal. 2018) and is dominated by two
fundamental ethical principles-autonomy and protection (Moye etal. 2013; Marson
et al. 2009). In general, there are three approaches to decision-making capacity,
namely, the status, outcome and the functional approaches. The status approach to
decision-making capacity translates to an all or nothing approach. Thus, once
deemed incapacitated under this legislation, decisions are (generally) made without
recourse to the individual. Deemed not to have decision-making capacity, this is the
A. Phelan and P. Rickard-Clarke
27
standard for all levels of decisions; in other words, cognitive impairment means
there is a permanent lack of decision-making ability which may be automatically
linked to certain medical or psychiatric diagnosis or involuntary admission to psy-
chiatric hospitals (Ganzini etal. 2004). Thus, in the case of wardship, a substitute
decision maker is appointed. Such guardianship arrangements are seen to be disem-
powering and contrary to Article 12 of the United Nations (UN) Convention the
Rights of People with Disabilities (Flynn and Arstein-Kerslake 2014).
Another perspective, the outcome approach focuses on the perceived poor con-
sequences of the decision; it is subjective. Thus, if deemed a risky decision, the
individual may be considered not to have relevant decision-making capacity and
consequently denied independent decision-making ability. Both the status and out-
come approaches are contrary to person centredness and are underpinned by a
paternalistic perspective.
The third approach to decision-making capacity is the functional approach. This
is founded on the principle of alwaysassuming decision-making capacity unless
otherwise proven and is time, issue and decision specic. Functional approaches are
based on the person having relevant information in an appropriate format, being
able to retain and weight up the options (reasoning), making a voluntary decision
and being able to communicate the preferred option. This facilitates an appreciation
of uctuating capacity and recognizes that decision-making capacity can depend on
issues such as level of complexity, amount of information, understanding and the
competency of the communicator to support the person and assist in optimizing and
augmenting understanding and enabling compromise when a decision is impossible
(Featherstonhaugh etal. 2016).
While there are a number of published capacity assessment tools, there is not any
consensus on a standard approach although dedicated capacity training does
increase inter-rater reliability (Pennington etal. 2018). Equally, Pennington etal.
(2018) observe that some of these tools may contradict legislative imperatives in
both the United Kingdom and Ireland, such as the explicit expression of choice or
the need of choice to be rational. Capacity tools that have been used are, for the most
part, tools which assist with a clinical diagnosis focusing on a disability (the medi-
cal model) rather than on the person’s ability to make a decision. Thus, such tools
need ‘cultural proong’ to ensure they align with contextual use as well as ensuring
the evaluator (i.e. health care professional) understands the principles of appropriate
assessment using a functional approach.
Within progressive diseases such as dementia, the executive functioning of the
brain, which controls higher order and abstract thinking can deteriorate rst (Guarino
etal. 2019). Accordingly, decisions around the management of nances can be a rst
indication of challenges in decision-making capacity. Specic nancial capacity
assessments can be useful to assess nancial management ability and importantly,
enable the person to take appropriate steps (Martin etal. 2008; Marson etal. 2009) and
further support can be provided in the context of continued decision- making deteriora-
tion. What is required is what Flynn and Arstein-Kerslake (2014) identify as an acces-
sible continuum of support which is scaffolded by enabling conditions (advocacy,
3 Person Centred Approaches inCapacity Legislation
28
advanced care decisions and options to multi-modal communication options) to pri-
oritize a person’s will and preference. Moreover, the socio-cultural aspect of capacity
needs to be appreciated, which includes life experience, genderized roles, religious
and ethnic perspectives on decision-making (Pennington etal. 2018).
3.4 A Rights Based Approach
Historically, personhood has been linked to the exercise of rights. Freeman and
Fraser (1994) observed how gender relationships limited personhood. Women’s
right to vote is only a relatively recent social and political achievement and the con-
cept of coverture, derived from English law, meant that women who married were
considered the chattel of their husbands thus hindering their rights and their experi-
ence of personhood (Finn 1996). Yet, the limitations to personhood extend beyond
gender. Rights can often be curtailed within marginalized groups, justifying dis-
crimination. Within the social control of dominant groups, there has been a hierar-
chy of rights based on issues such as age, citizenship, ethnicity, religion, caste, legal
status, social class, socio-economic group, disability (physical and/or cognitive),
thus positioning marginalized individuals as ‘others’. Such social distinctions typi-
ed rationales for different and unequal treatment which could also be supported in
law. For instance, prior to a legislative amendment in 1865, slaves in America were
considered three fths of a person (US Constitution Amendment 1865), while the
instigation of the 1935 Nuremberg Laws in Germany sanctioned the discrimination
(and depersonalisation) of the Jewish people laying the foundation for the Holocaust
(Heideman 2017).
While the concept of rights can be traced to the Code of Hammurabi (cica
1780BC) and the Cyrus Cylinder (580BC), modern understandings stem from the
middle of the twentieth century. There are two major lenses to consider rights-
citizenship rights and human rights. Both have an advantage over the concept of
personhood as a rights-based approach enables a political dimension to be explored
and also is concerned with power dynamics (Bartlett and O’Connor 2007). Although
both types of rights have similar and somewhat overlapping conceptual bases, there
are fundamental differences. Dominelli (2014) observed that human rights place an
obligation on nation-states to guarantee rights articulated by its ‘duty to care’ to its
citizens, which connects human rights to citizenship and national sovereignty. As
such, both human rights and citizen rights are important benchmarks to examine
standards of equality, equity and social justice. Rights are important tools to high-
light discrimination, particularly for marginalized groups such as those who have
decision-making capacity challenges. As human rights are frequently aligned with
decision-making capacity, citizen rights are briey considered before a more in-
depth review of human rights.
A. Phelan and P. Rickard-Clarke
29
3.4.1 Citizen Rights
Our modern concept of citizenship is premised on having a particular social identity
and belonging within national boundaries. Citizenship is a dening concept in state-
individual relations and has been subject to change being immersed in history,
social issues and political ethos. Theodore Marshall (1950) identied citizenship as
developmental and evolutionary, based on equality and comprised of three domains,
namely, social rights (welfare, food, shelter, healthcare), political rights (including
voting) and civil rights (freedom of speech, right to own property). While these
domains remain useful in delineating responsibilities of the state towards citizens,
more recent commentators note the need to expand understandings because of a
changed and transformed political and social landscape due to issues such as supra-
national integration and more uid immigration patterns (Guarnizo 2012).
3.4.2 Human Rights
The UN came into being in 1945 and its main purpose is to promote respect for
human rights through international co-operation. The Declaration on Human Rights
was produced in 1948 to delineate fundamental freedoms belonging to all human
beings. The focus of the Declaration was to ensure the atrocities of World War II
were never repeated. The Declaration did not directly create legal obligations for
states as it was not a treaty but it has had a profound inuence on the development
of international human rights law. The European Convention for the Protection of
Human Rights and Fundamental Freedoms was adopted in 1950 and came into
force in 1953. It was the rst instrument to give effect to certain of the rights stated
in the Universal Declaration of Human Rights and make them binding on States.
Since its adoption in 1950, the Convention has been amended a number of times and
supplemented with many rights in addition to those set forth in the original text
(European Court of Human Rights and Council of Europe 2013). Human rights are
considered interdependent and indivisible and may be supported through various
international and regional treaties as well as legislation (IHREC 2015). The core
features of the human rights treaties are the right to equality and non-discrimination,
the right to life, right to liberty, right to respect for private and family life but in spite
of such provision it has been necessary to develop treaties to ensure the respect the
rights of specic groups such as Convention on the Rights of the Child (UN 1989)
and Convention on the Rights of Persons with Disabilities (UN 2006).
The UN Convention on the Rights of Persons with Disabilities (CRPD) was
adopted in December 2006 and entered into force on 3rd May 2008. It is the rst
comprehensive human rights treaty of the twenty-rst century and is the rst human
rights convention to be open for signature by regional integration organizations (UN
2006). The European Union ratied the CRPD in 2010. While the CRPD did not
introduce new rights it followed decades of work by the UN to change attitudes and
3 Person Centred Approaches inCapacity Legislation
30
approaches to persons with disabilities. It takes to a new height the movement from
viewing persons with disabilities as “objects” of charity, medical treatment and social
protection towards viewing persons with disabilities as “subjects” with rights, who
are capable of claiming those rights and making decisions for their lives based on their
free and informed consent as well as being active members of society (UN 2006).
The purpose of the CRPD is to promote, protect and ensure the full and equal
enjoyment of all human rights and fundamental freedoms by all persons with dis-
abilities, and to promote respect for their inherent dignity (Article 1) and clearly sets
out State Parties obligations for the purposes of the convention. Article 3 sets out the
general principles which include respect for inherent dignity, individual autonomy
including the freedom to make one’s own choices, and independence of persons;
non-discrimination; full and effective participation and inclusion in society; respect
for difference and acceptance of persons with disabilities as part of human diversity
and humanity; equality of opportunity and accessibility. Article 4 sets out the gen-
eral obligations for States to adopt all appropriate legislative, administrative and
other measures for the implementation of the rights recognized by the CRPD and to
undertake to take all appropriate measures, including legislation, to modify or abol-
ish existing laws, regulations, customs and practices that constitute discrimination
against persons with disabilities.
In relation to States obligations, the CRPD is particularly directive with regard to
their obligation to ensure the right to equal recognition before the law of all persons
with disabilities. Article 12 provides that State Parties reafrm that persons with
disabilities have the right to recognition everywhere as persons before the law but
also to recognize that persons with disabilities enjoy legal capacity on an equal basis
with others in all aspects of life. Legal capacity was not dened in the CRPD but
helpfully the UN Committee on the CRPD dened legal capacity as the ability to
hold rights and duties (legal standing) and to exercise these rights and duties (legal
agency). The Committee conrmed that legal capacity is the key to accessing mean-
ingful participation in society. Wilson (2017) stated that in any interpretation of the
term ‘legal capacity’ it is crucial that there is a clear understanding that legal capac-
ity is conceptually very different form the concept of mental capacity. The concept
of mental capacity refers to the ability of individuals to make decisions for them-
selves– either on their own or with support, whereas by contrast, legal capacity is a
legal status or standing. Traditionally laws have conated these two concepts and
denied persons who had difculty making decisions of their fundamental legal sta-
tus of ‘legal capacity’ which they hold as human beings. Article 12 also imposes
obligations on States to take appropriate measures to provide access by persons with
disabilities to the support they may require in exercising their legal capacity thus
ensuring full and effective participation by people with disabilities not only in their
own lives but also in society.
Ireland signed the CRPD in 2007 but did not ratify it until March 2018. The
reason for the delay was that the implications of ratication is that a State is obliged
to ensure that its domestic legislation complies with the treaty provisions and is
subject to reporting obligations to the UN Committee to monitor compliance with
international human rights law. To enable ratication, Ireland enacted the Assisted
A. Phelan and P. Rickard-Clarke
31
Decision-Making (Capacity) Act (Irish Statute Book 2015 Act) (discussed below)
in2015.
While Ireland is to the fore in its compliance with the CRPD, the 2015 Act cur-
rently does not make any provision for compliance with Article 14 of CRPD which
relates to liberty and security of person. New legislation is anticipated which will
add to Part 13 of the 2015 Act to provide a legislative framework for protection of
liberty safeguards for persons with disabilities.
The protection of human rights continues and there is now a growing realization
that yet a further international convention is required as existing human rights
mechanisms fail to adequately protect and promote the rights of older people. The
UN established the Open-ended Working Group on Ageing in 2010. Its purpose is
to strengthen the protection of older people’s rights by reviewing how existing
instruments address older people’s rights, identify gaps in protection, and explore
the feasibility of new instruments (Help Age International n.d.).
3.5 The Legislative Turn toPerson-Centredness
This section examines the case of the Irish Decision Making Capacity Act and also
considers legal commentaries which have underpinned an increased legal apprecia-
tion of the concept of person centrerdness. This has been demonstrated by support-
ing an individual’s self-determination, authentic voice and happiness.
3.5.1 The Assisted Decision Making Capacity Act: Placing
thePerson First
In December 2015, new Irish legislation was signed into law. This updated the
archaic 1871 Lunacy Regulation Act based on a status approach to capacity. Within
the mental capacity legislation in the United Kingdom (2005), the term ‘best inter-
ests is used rather than will and preference. Flynn and Arstein-Kerslake (2014)
point to the subjectivity in the term as ‘best interests’, like beauty, is in the eye of
the beholder. Rather, Irish legislation applies the principles of supporting the per-
son’s will, preference, values and beliefs. The 2015 Act establishes a modern legal
framework to support decision-making and sets out a number key principles
(Guiding Principles) that apply before and during any intervention in respect of a
person who may be the subject of the legislation. An intervention, dened as an
action taken, orders made or directions given under the Act, in respect of a person,
must be in a manner that minimizes the restriction of the person’s rights and the
restriction of the person’s freedom of action and have due regard to the need to
respect the right of the person to dignity, bodily integrity, privacy, autonomy and
control over his or her nancial affairs. The Guiding Principles also include the
participation by the person in any intervention in so far as practicable and the giving
3 Person Centred Approaches inCapacity Legislation
32
effect to the past and present will, preferences, beliefs and values of the person in so
far as reasonably ascertainable (Section 8 2015 Act). From the Irish perspective, the
2015 Act provides that the capacity of all existing adult wards of court will, on the
commencement of the new legislation, be subject to a review. The applications of
many wards will have been based, as stated above, on the status approach to capac-
ity whereas the 2015 Act provides that a person’s capacity (to include wards subject
to review) is to be construed functionally and provides that a person’s capacity shall
be assessed on the basis of his or her ability to understand, at the time that a decision
is to be made, the nature and consequences of the decision to be made by him or her
in the context of available choices at that time (Section 3 2015 Act). All wards will
be discharged from wardship and those that continue to need support will transition
to the supported decision-making arrangements contained in the 2015 Act.
The Act also enables a spectrum of legal supports to enable the will, preference,
values and beliefs. In the context of having decision making capacity, an individual
can arrange to have an advanced healthcare directive or arrange an enduring power
of attorney. This enables them to select a person who will act on their behalf (accord-
ing to the Guiding Principles). For those who are experiencing decision-making
capacity challenges, there are three options which allow for different levels of deci-
sion making capacity. Firstly, an individual can have a decision-making assistance
agreement. The appointed person will access and help to explain relevant informa-
tion and discuss issues with the person, but the decision remains with the individual.
Secondly, a co-decision maker is chosen by the individual to assist in the same way
as the decision making assistant, but makes the decision with the individual. For
individuals who do not have decision making ability, a decision making representa-
tive may be appointed by the Circuit Court to act on behalf of the individual and
according to the Guiding Principles, which are underpinned by directing decisions
according the individual’s will, preference, values and beliefs.
3.5.2 Legal Commentaries Underpinned bya Person Centred
Approach
While the philosophy of person centredness has existed in health for a number of
decades, recent legal discourses have sought to reiterate the central concepts of
autonomy and self-determination. Case law in Ireland as far back to 1996 has con-
sidered capacity to make decisions as requiring a legal assessment. In In re Ward of
Court (withholding medical treatment) No. 2[1996] 2 I.R. 79, the Court stated that
an adult is presumed to have capacity and whether a person has capacity to execute
an instrument requires an understanding of the nature, purpose and effect of an
instrument executed by him or her. In Fitzpatrick v. F.K. [2008] IEHC 104, the court
linked the question of capacity to theability to understand information, understand
the consequences of an action, of a choice made and to be in a position to weigh
information an alternative choices and likely outcomes. In SCR [2015] IEHC Baker
J. stated:
A. Phelan and P. Rickard-Clarke
33
I consider then that the question of cognitive capacity requires the court to make a legal
assessment of such capacity and that the court ought not, in the case of the execution of an
instrument creating an EPA, defer to a medical assessment even one made following a con-
temporaneous or near contemporaneous assessment.
Justice Baker concluded that the ‘test is a legal test’ The legal test has now been
given statutory effect in the Assisted Decision-Making (Capacity) Act 2015 which
provides that:
A person lacks the capacity to make a decision if he or she is unable –
to understand the information relevant to the decision,
to retain that information long enough to make a voluntary choice,
to use or weigh that information as part of the process of making the decision, or
to communicate his or her decision…by any means…(Section 3(2) ADMC Act 2015)
In particular, commentary by various judges in the United Kingdom point to the
imperative of including the person’s voice and perspective in care. In the case below,
Re M., the person did not wish to remain in a nursing home, despite relevant author-
ities lobbying to have her legally detained there:
In the end, if M remains conned in a home she is entitled to ask “What for?” The only
answer that could be provided at the moment is “To keep you alive as long as possible.” In
my view that is not a sufcient answer. The right to life and the state’s obligation to protect
it is not absolute and the court must surely have regard to the person’s own assessment of
her quality of life. In M’s case there is little to be said for a solution that attempts, without
any guarantee of success, to preserve for her a daily life without meaning or happiness and
which she, with some justication, regards as insupportable. (Jackson 2013)
The paternalistic approach to care is also represented in the excerpt below, where
Judge Eldergill points to the function of authorities as serving the person rather than
assuming authority over decision-making:
Therefore, it is her welfare in the context of her wishes, feelings, beliefs and values that is
important. This is the principle of benecence which asserts an obligation to help others
further their important and legitimate interests. In this important sense, the judge no less
than the local authority is her servant, not her master. (Eldergill 2014)
Fundamentally, these commentaries have considered how care authorities place
a major focus on risk, without appreciating that making an unwise choice is an
entitlement for people who demonstrate functional capacity and objective capacity
assessment is essential underpinned by supported decision-making:
…risk that all professionals involved with treating and helping that person– including, of
course, a judge in the Court of Protection– may feel drawn towards an outcome that is more
protective of the adult and thus, in certain circumstances, fail to carry out an assessment of
capacity that is detached and objective. (Baker 2012)
Enabling authentic decision-making involves a sensible approach, which also
considers the person’s happiness. Paternalism may work at the extreme of taking the
outcome approach to capacity, where unwise decisions are deemed untenable.
3 Person Centred Approaches inCapacity Legislation
34
The emphasis must be on sensible risk appraisal, not striving to avoid all risk, whatever the
price, but instead seeking a proper balance and being willing to tolerate manageable or
acceptable risks as the price appropriately to be paid in order to achieve some other good–
in particular to achieve the vital good of the elderly or vulnerable person’s happiness. What
good is it making someone safer if it merely makes them miserable? (Munby 2007)
Consequently, assessment of risk within decision-making requires a careful
deliberation on the balancing of rights:
Risk cannot be avoided of course. All decisions that involve deprivation of liberty or com-
pulsion involve balancing competing risks, of which the risk that others may suffer physical
harm is but one. For example, detention and compulsory care or treatment may risk loss of
employment, family contact, self-esteem and dignity; unnecessary or unjustied deprivation
of liberty; institutionalisation; and the unwanted side-effects of treatment. (Eldergill 2014)
In Ireland, it will be interesting to see the practical implementation of the 2015
Act when fully commenced and the giving effect to and interpretation by the court
of the principles set out in the Act.
3.6 Conclusion
This chapter has examined the concept of person centredness and how its central
principles of individualism, self-determination and intrinsic worth of every human
being has been supported through human and citizen rights discourses and within
contemporary legal discourses. An individual’s will, preference, values and beliefs
are fundamental to enabling personhood. Consequently, it is imperative that profes-
sionals and society recognize and defend the right of all people to make decisions and
to act on their own behalf. Human rights are everyone’s business and are important in
every setting and for every person. To conclude, it is useful to consider the words of
Eleanor Roosevelt (1958), who chaired the Human Rights Commission and was a
pivotal force in the establishment of the Declaration of the Human Rights (UN 1948).
Where, after all, do universal human rights begin? In small places, close to home– so close
and so small that they cannot be seen on any maps of the world. … Unless these rights have
meaning there, they have little meaning anywhere. Without concerned citizen action to
uphold them close to home, we shall look in vain for progress in the larger world.
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3 Person Centred Approaches inCapacity Legislation
39© Springer Nature Switzerland AG 2020
A. Phelan (ed.), Advances in Elder Abuse Research, International Perspectives
on Aging 24, https://doi.org/10.1007/978-3-030-25093-5_4
Chapter 4
Elder Abuse inIsraeli Society– Legislative
Acts andSpecial Services
ArielaLowenstein andIsrael(Issi)Doron
4.1 Introduction
The demographic structure of developed societies is changing, and rates of older
persons are constantly increasing. Thus, in Article 25 of the Charter of Fundamental
Rights, the European Union already recognised and respected the rights of older
people to lead a life of dignity and independence, and to participate in social and
cultural life. Accordingly, the challenge today and for the future will be to tackle
this demographic change in an afrmative way, eschewing any sense of old age
being a burden on society or posing a threat to the individual.
Part of this challenge includes combating elder abuse and neglect– a relatively
neglected issue that still tends sometimes to be trivialized and pushed into the back-
ground. Older people who are dependent on care and/or are isolated within their
own homes, or in care facilities, are especially prone to it. Care in the home brings
with it several strains, not least for the health, wellbeing and social contacts of those
providing that care. Families sometimes must sacrice a great deal to look after
older relatives. Caring for older people who suffer from dementia presents a special
strain.
The ability of families today to continue providing care for frail elders in view of
changing family structures, increasing female participation in the workforce, chang-
ing work-life balance and longer working life (Daatland and Lowenstein 2005;
Attias-Donfut and Wolff 2003) is becoming thus more difcult. All this may lead to
incidences of abuse and neglect.
A. Lowenstein (*)
Social Gerontology, Center for Research and Study of Aging Department of Gerontology,
Haifa University, Haifa, Israel
e-mail: ariela@research.haifa.ac.il
I. (Issi)Doron
Department of Gerontology and The Center on Research and Study of Aging,
University of Haifa, Haifa, Israel
40
Elder abuse is still one of the most hidden forms of mistreatment and a key to
governmental responses to an ageing population. It is an important facet as a family
violence problem, an inter-generational concern, as well as a public health, justice
and human rights issue. Neglect, abuse and violence had been already identied at
the 2002Second World Assembly of Aging in Madrid (MIPAA 2002) as an impor-
tant issue affecting the well-being of older people around the world, and since then
have received a growing global awareness.
In this chapter, we will try to describe how a specic society– in this case, the
state of Israel – has tried to address the social phenomenon of elder abuse and
neglect. Specically, we will try to describe how legislation and social services were
developed and transformed throughout the years, in an attempt to combat and pre-
vent its existence. While local and specic, the Israeli experience can have much
broader lessons on the limitations of law and social policy as tools for social change,
and on future directions for actions that are still needed.
4.2 Israeli Society
Israeli society is a multi-cultural, pluralistic society that includes a variety of
national, religious, and ethnic groups. It has a strong traditional and family-oriented
culture which mixes the Jewish majority’s traditions and religious values with those
of the country’s Muslim, Christian, and Druze minorities (groups that constitute
about 25% of Israel’s population) (Brodsky etal. 2016). Israel is also an urbanized
welfare state. Its welfare policies and legislation are shaped by a mixture of govern-
mental and market forces, all of which impact elder abuse and neglect.
In Israel, as elsewhere in the modern world, society is undergoing a process of
population ageing. The 2016 census shows that the aged (65+) comprise about 12%
of the total population (Central Bureau of Statistics (CBS) 2016). In Israel currently,
life expectancy is high: 84.6 for women and 81.2 for men (CBS 2016). The Israeli
population is expected to continue to age, and it is forecasted that by 2025 the propor-
tion of old people will reach 14%. In addition, there will be a further increase in life
expectancy and the birthrate will continue to decline (Brodsky etal. 2016). Currently,
the 75+ age group is close to 45% of the older population, and 87% of them are com-
munity dwellers (CBS 2016). This age cohort is the most vulnerable and can suffer
from limitations in daily functioning and chronic diseases. Close to 14% of commu-
nity dwelling elders report a disability or activities of daily living (ADL) difculties.
The percentage is higher among new immigrants (close to 17%) and even higher
among non-Jews, nearing 30% (CBS 2016). This is congruent with data from the
United States, indicating that socio-cultural factors are related to the incidence of
chronic disease among older adults. This portion of the population needs closer care
and assistance, which is still mostly provided by family members. Since older persons
usually prefer aging at home– aging in place– the expectation is that needed care will
be provided by the informal system– the familial system, usually adult children.
Studies show that family members provide most of the care for disabled elders
(Lowenstein and Katz 2010; Lowenstein 2003). Thus, elder care can be a stressor
A. Lowenstein and I. (Issi)Doron
41
and even a source of conict in family relations. The physical, emotional and eco-
nomic burden of caring for an elder family member presents a growing challenge to
societal priorities regarding elders and their families.
The traditional family values in Israel created for some decades a wrong picture
of “elder abuse free society” until the late 1990s (Lowenstein and Ron 2000;
Lowenstein 2003; Lowenstein and Doron 2013). Then, the study of elder abuse and
neglect became visible in Israel especially after the First National Survey among
1045 community dwelling elders, Jews and Arabs, was conducted (Lowenstein
etal. 2009). Its ndings were presented at the President of Israel chambers and at
the Health and Welfare Committee of the Israeli Parliament.
The survey provided the rst National Database regarding the phenomena.
Relatively, a high proportion of abuse and neglect was detected– 18.4% among
older persons who reported that they had been exposed to one or more types of harm
during the year prior to the survey. The ndings were higher compared to other
surveys conducted at that time (e.g. Pavlik etal. 2001; WHO 2011; Yan and Tang
2001; NCPOP 2012). It is probably because of an elder abuse and neglect broad
denition as well as using a multitude of survey tools (Lowenstein and Doron 2013).
A low proportion of physical and sexual abuse was reported (2.3%) which is
similar to ndings in other countries. It may be related to the fact that physical and
sexual abuse are usually combined with other abuse types. However, these rates
were quite high among Arab women which corresponds to ndings from other
countries like studies conducted in People’s Republic of China (Dong and Simon
2010) and India (Chokkanathan and Lee 2005; Sebastian and Sekher 2011).
Financial abuse rates in the survey were 6.6%, verbal abuse 16%, most of it com-
bined with other abuse types and 17% reported that they had experienced neglect
(Lowenstein etal. 2009). The survey results indicated that elder abuse and neglect
are a social and health issue related to human rights and social solidarity.
Since then, Israel has undergone a dynamic transition and change regarding elder
abuse and neglect in varied areas– research, policy, legislation and social interven-
tions. The elder abuse and neglect phenomenon had moved to the forefront of pub-
lic, professional and political awareness (Lowenstein and Doron 2013).
4.3 Policy, Legislation andService Developments
Elder abuse can only be effectively prevented by action at the appropriate national
level. Such national plans were already developed in Ireland in 2002, the Check
Republic in 2013 and in Singapore in 2016. Thus, after a variety of innovative leg-
islative acts and service developments which were already in place, and will be
described below, it was understood that to combat abuse, policy action in the form
of a National Action Plan must be drawn up. Such a plan should include general
guidelines and relevant legal bases to be established.
Currently, the Israeli Gerontological Society, headed by Prof. Y.Brick, with the
involvement of several members, including Prof. Lowenstein, prepared A National
Plan for Care of the Older Population, relating to the major issues in the eld of
4 Elder Abuse inIsraeli Society– Legislative Acts andSpecial Services
42
aging, including elder abuse and neglect. A special Parliamentary Committee had
been established, headed by the vice-chair of the Israeli Parliament. This Committee
meets bi-weekly and discusses the various topics of the plan. In the area of elder
abuse and neglect, the following areas were suggested:
1. Prevention: This is through expansion of the work of the Special Units, which
were established within most Municipal Welfare Departments to tackle elder
abuse and neglect (it was one of the outcomes of the National Survey). Such
work should include providing more help to family carers, identifying popula-
tions at risk and publishing more newspaper articles on the topic and increasing
public awareness.
2. Identication: Emphasizing the role of family physicians, nurses and social
workers and those working at hospital admission units, as well as community
workers in special Elders’ Clubs and Day Care Centers to identify elder abuse. It
could be accomplished through more specic training on the topic, exposing the
professionals to new data.
3. Intervention and Treatment: Providing on-going training to professionals working
especially within the Health and Welfare systems. This could be achieved by spe-
cial courses and workshops, developing training materials, using tools developed
in this area like some of the NICE– National Initiative for Care of the Elderly
(University of Toronto, headed by Prof. Lynn McDonald) pocket tools and others
such as the EASI instrument developed by Prof. Mark Yaffe etal. (2008) in Canada.
4.4 Developments WithintheHealth andWelfare Systems
inIsrael
As older persons consume health and medical services in a relatively higher propor-
tion and frequency than other age groups, it puts the health system’s professionals,
and especially family physicians and those in the admission units in hospital set-
tings, in a situation where their accessibility to this population is high. The health
system is, thus, one of the main gatekeepers, regarding prevention and treatment.
Previous studies show that abuse rates among hospitalized elders are higher than in
the general population. The reason may be due to extensive examinations that help
in identication of abuse cases (e.g., Cohen etal. 2007).
The system in Israel focused on data dissemination among medical institutes to
identify elder abuse cases. In addition to primary legislation– which will be described
in detail below– a series of internal directives issued by the Director- General of the
Ministry of Health has been published in 2003–2005. These directives deal with iden-
tifying victims of domestic violence (General Manager Circular 22/2003). Other cir-
culars state that the aim is to “Broaden and deepen identication of and care for the
aging population, from the moment suspicious is aroused…” (Clause 2.3). The circu-
lar obligates each health system – especially big hospitals – to establish Violence
Committees, led by a senior physician and a senior social worker, who are responsible
A. Lowenstein and I. (Issi)Doron
43
for receiving reports, rst from the Admission Units and from the various hospital
departments, if abuse was detected. These reports should be forwarded to relevant
agencies (welfare services, police and/or Health Ministry) as cited:
…the committee’s roles are: to supervise, monitor, and accompany the abuse cases’ or
apprehension for abuse cases’ treatment. To implement the circular directives including
reporting and recommendations of operational options to management according to chang-
ing needs (General Manager Circular, 22/2003).
Paragraphs 8–10in the circular are dealing with treatment methods in each abuse
or apprehension for abuse cases, in defending the victim during hospitalization and
in action taken during hospital discharge. This includes establishing a continuum of
care with relevant community welfare and social services. Paragraph 11in the cir-
cular obliges each committee member to report on cases he/she had encountered.
Therefore, there is a need for multi-disciplinary team collaboration in the process of
identication of elder abuse and neglect and maintaining a continuum of care
between hospitals that older victims’ visit and the community (sick funds– HMO’s,
welfare services and the police).
The Welfare Ministry, after understanding the issue emanating from the results
of the National Survey, decided to create Special Units with the different Welfare
Departments at the municipal level. These units are operating as multi-system units
working on the development of close relations with other services like community
health clinics (HMO’s), hospitals, elders’ organizations, the police and the legal
system to create continuity of care.
The units provide direct interventions to abusers and victims, raise public aware-
ness, and support all professionals who work within the area of the respected munic-
ipality. The social workers in these units try to detect abuse cases, provide information
to elders regarding their rights and the services available. In parallel, staff work with
caregiving family members, providing them with knowledge and treatment abilities
and informing them about existing rights and services. The units are also involved in
community activity: providing information intended to increase awareness among
elderly, professionals and the public. During the year 2015, more than 5000 elders
suffering from abuse and neglect around the country were identied and treated by
the existing 62 special units (Ministry of Welfare-Alon and Yuz 2015).
4.5 Legislative Developments
4.5.1 The Legislative Developments Prior tothe2016
Guardianship Law Reform
Israel has a rich history of legislative attempts to address the phenomena of elder
abuse and neglect. This legal history has been described elsewhere (Doron etal.
2005; Lowenstein and Doron 2008, 2013) and can be summarized as a “legislative-
generational” developmental process.
4 Elder Abuse inIsraeli Society– Legislative Acts andSpecial Services
44
The rst legislative generation of Israeli laws were enacted during the 1950s and
1960s, Typical examples included Israel’s Legal Capacity and Guardianship Law of
1962; or the Defense of Protected Persons Law, of 1966. These laws did not view
elder abuse and neglect as a specic or unique social phenomena but part of a broader
social phenomena of social deviance or of helpless populations. As a result, this leg-
islation “bundled” up older people in the same legal framework of various other
“protected” populations such as children, persons with cognitive disabilities, men-
tally ill, or drug addicts. These laws commonly provided legal authorities via local
social welfare ofcers, to intervene in the lives of older persons who were not able to
care for themselves or were subject to abuse or neglect. Such typical interventions
included either forced hospitalization, or placement under formal guardianship.
The second legislative generation in the eld, which characterized the 1980s,
continued to ignore the uniqueness of elder abuse and neglect. However, it reected
a sense of failure of social welfare authorities to efciently combat cases of abuse
of weak or frail populations. The outcome was a new wave of legislation which
adopted this time a more criminal legal approach: preventing, deterring and punish-
ing via the criminal justice system. The outcome was a major addition (Amendment
No. 26, 1989) to Israel’s Criminal Law of 1977, which for the rst time incorporated
a specic reference to abuse and neglect of minors and “helpless persons” (older
persons being viewed as part of this group), in its various forms (physical, mental,
and sexual), and dened it as a unique criminal offence. Moreover, the new criminal
legislation introduced, for the rst time, a very broad mandatory reporting mecha-
nism, mandating not only professionals, but any person with reasonable suspicion
of elder abuse, to report it either to the police or welfare ofcers.
The third wave of legislative development continued with the lack of specic
reference to elder abuse as such, but tried to address this phenomena via a new broad
legal approach: family violence laws. Stemming from feminist and women’s rights’
perspectives, Israeli law tried in the early 1990s, to adopt a new approach to address
intimate and family violence. This approach recognized the failure of “traditional”
criminal and social law approaches and tried to adopt a legal ideology which empow-
ered the victims (mostly women) by handing them the power to initiate protective
legal proceedings, without being dependent on police or welfare ofcers.
The most important outcome was the enactment of Israel’s Prevention of Violence
in the Family Law of 1991, which for the rst time authorized victims of family
violence to access Family Courts in an independent manner, in order to receive
protective orders against their predators. Furthermore, it authorized the courts to
issue treatment orders and have both sides engage in mediation and other alternative
dispute resolution mechanisms as part of the legal process.
The fourth and nal wave of legislative development in Israel, prior to the recent
guardianship law reform, was held in the early 2000s. As described above, it was
only in the 1990s and early 2000s that Israeli society was exposed to the phenomena
of elder abuse and neglect– as a distinct social challenge. The combination of both
the ground breaking empirical ndings of Lowenstein (1998) along with the rst
national report and policy recommendations in the eld (Eshel 2001) triggered a
range of specic legal reactions. These new statutory developments were for the
A. Lowenstein and I. (Issi)Doron
45
rst time specically and directly targeted at elder abuse and neglect, as such, and
not as part of a broader law reform or bundled up with other protected populations.
One example of this new specic and direct response was the series of obligatory
regulatory directives issued by the Ministry of Health, which were described in
detail above. Another example of this new wave of direct and specic reform was an
amendment to Israel’s criminal code, not in the general context of abuse and neglect
of “helpless” persons as a whole, but rather in dening a new specic criminal
offence of battery of an older person along with providing a more severe punishment
on such an offence compared to battery of a person which is not an older person.
To conclude, it could be argued that until the very recent major law reform of
2016, which will be described further below, the overall legislative developments in
the eld of elder abuse and neglect in Israel could be described as follows (Table4.1):
It should be noted that these legislative shifts and “generational” developments
were not unique to Israel. Various countries around the world have reformed their
laws or enacted new pieces of legislations in order to address the newly exposed
reality of elder abuse and neglect (e.g. Montegomery etal. 2016). Moreover, similar
to the Israeli case, critics and concerns were raised in various jurisdictions with
regards to the merits and success of these reforms to actually make a difference and
promote the rights of older persons (e.g. Kohn 2012).
4.6 Israel’s 2016 Guardianship Law Reform
In the last 3 years, a signicant development has occurred in Israeli legislation
which relates to the eld of elder abuse and neglect: a major law reform in the eld
of adult guardianship (Kanter and Tolub 2017). Historically, Israel’s Legal Capacity
and Guardianship Law of 1962 has been under ongoing criticism for being over
Table 4.1 The generational development of Israeli legislation
Time Rationale
Legal Foci of
Power
Statutory
Example Elder Specic?
Gen.
1
1950s–1960s Social control and
protection of
helpless
populations
Social welfare
ofcers
Legal Capacity
and Guardianship
Law 1962
No– Part of
“helpless
populations”
Gen.
2
1980s Deterring and
punishing +
reporting
Police/ criminal
justice
Criminal law
(amendment),
1989
No– Part of
“helpless
populations”
Gen.
3
1990s Removal and
treatment
The victims Prevention of
Family Violence
Law 1991
No– Part of
victims of
family violence
Gen.
4
2000s Mix: Awareness,
early detection;
social intervention;
criminal deterrence;
Mix: Older
persons and
professionals
Ministry of
Health Directives
2003–5
Yes
4 Elder Abuse inIsraeli Society– Legislative Acts andSpecial Services
46
paternalistic, ageist, and harmful in allowing, too easily, to strip older persons from
their legal rights, under the guise of protection and care (Doron 2004). Therefore,
and after years of political struggle, the Israeli Parliament, enacted a major law
reform which will be described hereby.
Three main elements were included in this law reform:
4.6.1 The Establishment ofaSupportive Decision Making
Mechanism asanAlternative toFormal Guardianship
Until the recent law reform, the typical legal approach in Israel towards legal capac-
ity was a binary approach: either the person had legal capacity– which meant he or
she were fully autonomous and capable of all legal actions; or did not have legal
capacity– which meant that he or she needed a formal guardian to provide substi-
tute decision-making, based on the best interests of the person. The outcome was
that for many older persons, even in early stages of mental disability (e.g. the begin-
ning of dementia), or even of physical disability (e.g. the inability to move indepen-
dently), being placed under total guardianship while losing all independent legal
status was very easily done (Doron 2004).
It was actually Israel’s signing and ratifying the International Convention for the
Rights of Persons with Disabilities (CRPD) (UN 2006), which triggered the public
discussions around the need to develop supportive mechanisms which will allow
older persons (and others) to maintain their independence, autonomy, and legal
capacity, even in cases of disability. The disability rights movement raised the
awareness that support systems can empower and enable older persons to maintain
their ability to control their lives and have their wishes voiced and honored (Kanter
2009). The outcome was that for the rst time, Israel law formally recognized the
legal ability to have a “supportive decision maker” as an alternative to formal guard-
ianship, which mirrored a broader socio-legal shift moving away from guardianship
to supported decision-making (Diller 2016).
4.6.2 The Establishment ofContinuing Power ofAttorney
forProperty andPersonal Care asanAlternative
toFormal Guardianship
Prior to the recent law reform, very few legal alternatives existed with regards to
older persons who were starting to lose their mental capacity or were having dif-
culties in managing their affairs due to physical or mental dependence. Moreover,
research indicated that even the very limited existing alternative which did exist was
mostly unknown or not used (Doron and Gal 2006). As part of the recent law reform,
A. Lowenstein and I. (Issi)Doron
47
a newly established legal mechanism was adopted– a continuing power of attor-
ney– enabling capable adults to nominate an agent to be their power of attorney in
cases future incapacity. Such binding legal documents can not only prevent the need
for formal guardianship, but can also secure that the personal preferences and
wishes will be respected and honored.
4.6.3 Reforming Existing Guardianship Regime
astoMinimize Its Scope, andTransforming It
toanOption ofLast Resort
The third major element of the recent law reform addressed some of the weaknesses
that existed in the “traditional” guardianship system. The changes made reected
the shift in social values and in the need to improve procedural justice. For example,
it is now mandated under the newly reformed law, that formal guardianship will be
only a tool of last resort and be requested only after all other less restrictive legal
alternatives have been exhausted. Moreover, the burden of proof is on the side who
asks for guardianship to show that no other less restrictive alternatives were avail-
able. The standard of decision making and the view point of the guardianship has
also shifted form an “objective” best-interest criteria, to a subjective, personal pref-
erences criteria, mandating guardians to make all efforts to gather and reect in their
actions, the personal values and preferences of the person under guardianship.
Overall, the 2016 guardianship law reform was much more than a simple law
reform. It reected a major shift in Israel’s policy from an ideology focused mostly
on protection and paternalistic intervention in the lives of older persons to an ideol-
ogy which is founded on respecting autonomy, personal freedom, and the recogni-
tion for the need of support (and substitution) in order to secure them (Kanter and
Tolub 2017). While it was not a direct and specic reform in the eld of elder abuse
and neglect, it certainly sent an ideological “message” in that eld as well. The mes-
sage is that Israeli society needs to focus its efforts to intervening before cases of
abuse and neglect have been identied. The efforts need to be focused in prevention,
support and empowerment, enabling older people, despite natural decline or new
disabilities, to continue to be independent, and have their wishes and preferences
honored, hence securing and preventing the ability to abuse or neglect them.
4.7 Conclusion
To sum up, we have demonstrated that research and a national database can impact
policy, service developments and legislation. During the last two decades Israel
made advanced strides in combating elder abuse and neglect. However, we should
4 Elder Abuse inIsraeli Society– Legislative Acts andSpecial Services
48
continue this work and explore and develop additional intervention and prevention
services and devise more innovative care models. An integrative approach is needed
to coordinate the work and create partnerships between the criminal-legal system
and the health-welfare systems.
It is also important to work on translating successful policies and initiatives into
new contexts as suggested by the National Plan for Care of Elders to contribute to
increasing awareness of elder abuse and neglect and to create sustainable action to
eradicate it. More collaboration should be advanced to allow systematic information
exchanges and alliance among all involved in elder care. We have to continue to
raise public and professional awareness on elder abuse and neglect.
Advances in our understanding of the many manifestations of elder abuse and the
emergence and development of inter-professional-team approaches shows the
important strides Israel has made in coping with elder abuse and neglect.
From a legislative reform perspective, Israel’s experience has seen some signi-
cant developments and transformation. The historical trend was a shift from an
emphasis on social welfare legislation targeting “helpless” populations, to a crimi-
nal justice approach along with mandatory reporting, to a more gendered prevention
of family violence model. All these developments were not “elder abuse” specic,
but covered the eld in practice. It was only in the early 2000s, that elder abuse and
neglect, as a unique and specic phenomenon, received a more direct and specic
legislative and statutory considerations, which was very diverse in its actual
content.
However, the legislative action in this eld received a major shift as part of the
recent adult guardianship law reform. While not “elder abuse” specic, this new and
signicant reform reected a much deeper change in ideology and social values
which indirectly affect the legal policies in the eld of elder abuse and neglect.
Echoing the CRPD (U.N. 2006), the changes in legislation, the restriction and mini-
malization of “traditional” guardianship, along with the establishment and promo-
tion of both advance legal planning, and more importantly, supportive
decision-making mechanisms, mirrored the focus of enabling independence, and
combating abuse and neglect by empowering the older population via supportive
services, and through a new social construction of vulnerability and dependency.
As this reform is very new, and as the whole concept of supportive decision-
making is in its infancy, it is yet to be seen to what extent it is actually successful in
preventing or reducing elder abuse and neglect. While there is little experience with
supportive decision-making, other countries’ experience with continuing powers of
attorney show that while they may empower and prevent unnecessary guardianship,
they may by themselves be tools for abuse and exploitation (Rhein 2009). Hence, it
is time to see the effects of Israel’s most recent law reform on the reality of elder
abuse and neglect.
In light of the above picture, some recommendations for future action and
research can be provided:
A. Lowenstein and I. (Issi)Doron
49
4.8 Need forEmpirical Legal Studies to“Measure”
andAssess theImpact ofLegislation
Quite surprisingly, despite the wealth of legal changes and developments in Israel,
there is very little empirical or evaluative research which attempts to measure and
assess the degree of success or failure of the laws which attempt to make a difference
in the eld of elder abuse and neglect. For example, very little is known about the
success or failure of the 1989 legislative amendment which added the mandatory
legal requirement to report cases of elder abuse and neglect. There are those who
question the efciency and ability of such reporting laws to be effective in the eld
of elder abuse and neglect (e.g. see Doron etal. 2013, Kohn 2012). Without evidence
based legal practice, it is still a big question to what extent legislation alone and
which kind of legislation, specically, can actually make a difference in the eld.
4.9 The Need toAddress Legal andNormative Gaps
Despite the rich legal developments which were described above, there are still
some existing legal gaps within Israeli legislation. For example, the eld of nancial
abuse and exploitation was and still is missing a direct and specic reference under
existing law. More specically, a recent study in the eld of elder consumer fraud
has shown how existing consumer protection law in Israel fails to fully address the
unique challenges faced by older consumers. Hence, a specic effort should be
given at identifying existing normative gaps, while providing tailored legislative
responds (Segal etal. under review).
4.10 Allotment ofResources andProvision ofServices
Finally, while it has been raised in the past (e.g. Doron etal. 2005), it is still relevant
to re-emphasize the issue of the need to allocate public nancial resources alongside
the legislative reform process. A nancial analysis of the legislation pertaining to
elder abuse and neglect in Israel shows that most of the statutes do not require
resources to be allotted specically to deal with this issue. The applications of the
relevant laws, particularly those of the rst three generations, rely on existing gen-
eral, nancial and institutional systems and comprehensive budgets. For example,
welfare ofcers for the court who deal in general with older people, are employed
by local municipalities. Their responsibilities to deal specically with elder abuse
and neglect must be undertaken over and above their other responsibilities as social
workers caring for the aged; this is unlike welfare ofcers for the court dealing with
children or women at risk, who receive extra funding for these legal responsibilities.
4 Elder Abuse inIsraeli Society– Legislative Acts andSpecial Services
50
Even the most recent 2016 guardianship law reform did not include any new nan-
cial support. On the contrary, its goal was to reduce formal guardianship, alongside
increasing “privately-based” alternatives in the form of continuing powers of attor-
ney, or privately funded supported decision makers.
The unwillingness to allocate signicant nancial resources to fund social ser-
vices for older people may stem from the fact that they are not a politically strong
social group. Furthermore, any money allocated to help the aged, would therefore
have to be found at the expense of other, politically stronger, groups (Pearson and
Richardson 1993). Nonetheless, it must be recognized that progress in the struggle
against elder abuse can only be made if the law requires the allocation of resources.
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4 Elder Abuse inIsraeli Society– Legislative Acts andSpecial Services
53© Springer Nature Switzerland AG 2020
A. Phelan (ed.), Advances in Elder Abuse Research, International Perspectives
on Aging 24, https://doi.org/10.1007/978-3-030-25093-5_5
Chapter 5
Elder Abuse Policy, Past, Present,
andFuture Trends
PamelaB.Teaster, BrianW.Lindberg, andYuxinZhao
5.1 Introduction
The history of policy related to elder abuse spans more than 50years and reects an
evolving understanding by policymakers and the general public that rather than
being a private sphere, family matter problem, elder abuse is a public sphere prob-
lem. In fact, it is an issue of national import, touching such sectors as social ser-
vices, healthcare, law enforcement, and banking. As a social justice issue, societal
recognition of and action concerning elder abuse has been both protracted and cir-
cuitous. Although elder abuse dates back to the beginning of human history, the
problem has gained tractionrelatively recently. Given the attention paid to child
abuse and intimate partner violence against women, the historical lack of political
will to take action to prevent and punish elder abuse is surprising (Teaster etal.
2010).
In the chapter that follows, we consider examples of federal elder abuse policy in
the United States as well as major international initiatives. Our treatment reects
changing societal conceptions of aging, social justice, and recognition of the prob-
lem of elder abuse as one encompassing human rights.
P. B. Teaster (*)
Virginia Tech, Blacksburg, VA, USA
e-mail: pteaster@vt.edu
B. W. Lindberg
Public Policy Advisor, Washington, DC, USA
Y. Zhao
Virginia Tech, Blacksburg, VA, USA
54
5.2 Major National Efforts toAddress Elder Abuse
intheUnited States
The genesis of United States (US) policy on elder abuse dates to the 1950s when the
Department of Health, Education, and Welfare awarded grants for “protective ser-
vice unit“demonstration projects” (Blenkner etal. 1971). The 1961 White House
Conference on Aging (WHCoA) was also instrumental in highlighting this problem
(Dubble 2006). In 1962, Public Welfare Amendments to the Social Security Act
authorized payments targeted to states for establishing protective services and fund-
ing demonstration projects. The passage of the 1965 Older Americans Act (OAA)
increased awareness and advocacy concerning the needs and rights of older adults.
Though the OAA helped states develop programs to assist older adults in its early
iterations, it did not specically mention elder abuse. However, these two pieces of
federal legislation encouraged states to enact laws and protective services for older
adults (Dubble 2006).
In the 1970s and 1980s, progress as well as setbacks continued related to bring-
ing elder abuse into the fore of public consciousness. In 1971, the White House
hosted a second WHCoA. In 1974, the Social Security Act authorized Adult
Protective Services (APS) under Title XX, stimulating some states to create APS
units and to mandate reporting of elder abuse. In 1981, Title XX was converted to
the Social Services Block Grant (SSBG) with the unfortunate consequence of
under-resourcing sorely needed APS programs (Lynch 2016). Also in 1981, a third
WHCoA included the issue of elder abuse, and in the same year, the US House of
Representatives Select Committee on Aging produced a nationally galvanizing
report entitled Elder Abuse: An Examination of a Hidden Problem (Teaster etal.
2010).
In 1984, Congress passed the Victims of Crime Act (VOCA), which provided
nancial compensation to victims to cover costs caused by being a victim of crime,
including health care and lost wages. Though applicable to all ages of crime vic-
tims, VOCA improved services to victims of elder abuse and established the Crime
Victims Fund, which earmarked some funds to deal with elder abuse(Crime Victims
Fund 2017; National Association n.d.; Ofce of Victims of Crime n.d.).
In 1985, acting in his capacity as Chairman of the Subcommittee on Health and
Long-Term Care of the House Select Committee on Aging, US Representative
Claude Pepper of Florida, a champion of older adults for more than a decade, issued
a stunning report, Elder Abuse: A National Disgrace, which caught public attention
and inspired political action. In 1987, Congress passed the Omnibus Budget
Reconciliation Act (OBRA), requiring that nursing homes protect and preserve the
quality of life of residents. Regulations emanating from OBRA specically dened
elder abuse in the context of long-term care (LTC) facilities, mandated states’
responsibility to investigate abuse allegations against facilities, and required LTC
facilities to train staff on elder abuse prevention (Teaster etal. 2010). Also in 1987,
the reauthorization of the OAA dened and required that Elder Abuse Prevention
Services incorporate public education and identication of abuse and create
P. B. Teaster et al.
55
mechanisms to receive reports of abuse (Dubble 2006; Teaster et al. 2010). The
1987 reauthorization also strengthened LTC Ombudsman Programs so that they
could better deal with abuses in US nursing homes.
In 1990, Congress provided funding earmarked for elder abuse prevention–$2.9
million divided among 50 states, the District of Columbia, and the US Territories.
According to the National Adult Protective Services Association (2016), states were
spending an average of $45.03 per child and only $3.80 per adult on protective ser-
vices.’ Although the funding was inadequate, the Administration on Aging (AoA)
provided the scaffolding for continued action. In 1988, the AoA created the National
Center on Elder Abuse (NCEA), made permanent in the 1992 reauthorization of the
OAA. Title VII included Allotments for Vulnerable Elder Rights Protection
Activities: the Long-Term Care Ombudsman Program, Programs for the Prevention
of Abuse and Exploitation, and State Legal Assistance Development Programs
(Lindberg etal. 2011). About the same time, the House Select Committee on Aging’s
Subcommittee on Health and Long-Term Care issued Elder Abuse: A Decade of
Shame and Inaction (1990) and Protecting America’s Abused Elderly: The Need for
Congressional Action (1991). In 1992, The Family Violence Prevention Services
Act funded the National Elder Abuse Incidence Study (NEAIS), conducted by the
Administration for Children and Families and AoA, data from which helped support
assertions that many cases of elder abuse were reported to APS and/or local authori-
ties (Dubble 2006). In 1995, then President Clinton announced the fourth
WHCOA.Under the leadership of Executive Director Robert Blancato, the 1995
WHCoA devoted unprecedented attention to elder abuse, passing two resolutions
dedicated solely to the protection of vulnerable older adults(WHCOA 2015,2016).
5.3 Passage (Finally) oftheElder Justice Act
In 2010, the Elder Justice Act (EJA) became law as part of the Patient Protection and
Affordable Care Act (ACA). Representing a decade of effort by advocates and poli-
cymakers, the EJA was the rst federal law to state that ‘it is the right of older adults
to be free of abuse, neglect, and exploitation’ (Teaster etal. 2010). The EJA estab-
lished an Elder Justice Coordinating Council (EJCC) made up of designees of the
Secretary of Health and Human Services (HHS), the Attorney General of the
Department of Justice, and other federal agencies to foster coordination on elder
abuse throughout the federal government. Supplementing the EJCCis a 27-member
Advisory Board appointed by the Secretary and made up of diverse experts on elder
abuse, neglect, and exploitation. Unfortunately, membership forthe Advisory Board
has never been appointed. To enhance uniformity for research on elder abuse protec-
tions, the EJA requires the Secretary to promulgate regulations guiding researchers
(EJA 2014).
Establishing Forensic Centers Section 2031 (42U.S.C. 1397 l) authorizes ten
centers to develop forensic expertise pertaining to elder abuse, neglect, and
5 Elder Abuse Policy, Past, Present, andFuture Trends
56
exploitation; provide services in local communities, and make data available to
develop the capacity of geriatric health care professionals and law enforcement to
collect forensic evidence. Congress has not yet appropriated funding for this
purpose.
Strengthening Adult Protective Services Section 2042 (42 U.S.C. 1397 m-1.)
requires the Secretary of HHS to:
1. Provide funding to state and local APS ofces as well as funding for demonstra-
tion programs by state and municipal governments for training in methods of
detection or prevention.
2. Coordinate with the Department of Justice to collect and disseminate annual data
relating to the abuse, neglect, and exploitation of elders.
3. Develop and disseminate information and conduct training on best practices in
carrying out APS.
4. Conduct research related to the quality of APS programs.
5. Provide technical assistance to states and other entities that provide APS.
Congress has provided limited funding in addition to HHS from the Prevention
and Public Health Fund (PPHF) for elder justice activities. Six million dollars in
PPHF funds were used for ve state awards for Elder Abuse Prevention Intervention
Programs. In Fiscal Year (FY) 2015, the Administration for Community Living
(ACL) received a $4 million appropriation for demonstration grants to states to
enhance their APS systems. With FY 2016 funds, the ACL announced funding
opportunities under its Elder Justice Innovation Grants program, which included the
areas of self-neglect, abuse in guardianship, elder abuse forensic centers, and elder
abuse in Indian Country.
Enhancing the Capacity of Long-Term Care Settings Section 2041 (42U.S.C.
1397m) requires the Secretary of HHS, in coordination with the Secretary of Labor,
to provide grants to LTC facilities and community-based long-term care entities to
create incentives for direct care workers to seek, train for, and maintain employment
in long-term care facilities. The Secretary must adopt electronic standards for the
exchange of clinical data by LTC facilities and develop procedures to accept elec-
tronic submission of clinical data.
Section 2043 (42U.S.C. 1397m-2) provides grants to improve the capacity of
long-term care ombudsmen to respond to elder abuse and neglect, conduct pilot
programs, and provide support. Section 2046 combines a number of mandates to
accomplish the above objectives:
• Create a National Training Institute (42U.S.C. 13951-3a) to provide and improve
the training of surveyors to investigate allegations of abuse and neglect and mis-
appropriation of property in programs and facilities that receive payments under
Medicare or Medicaid.
• Require LTC facilities to report a crime or the reasonable suspicion of a criminal
act against a resident to law enforcement within 2h in the case of serious bodily
P. B. Teaster et al.
57
injury, or otherwise within 24h (42U.S.C. 1320b-25). Failure to comply with
this regulation or retaliation against any reporter will trigger substantial civil
monetary penalties.
• Require the Secretary to study the need to establish a national nurse aide registry
and to report its ndings to the EJCC and specied congressional committees by
September 2011 (EJA 2014).
Finally, two related provisions in the ACA not technically part of the EJA deserve
mention. Section 6121 amends initial training requirements for nursing facility staff
to include training in dementia management and patient abuse prevention. Section
6201 requires the Secretary of HHS to establish a program to identify efcient,
effective, and economical procedures for long-term care facilities to conduct back-
ground checks on prospective direct patient access employees on a nationwide
basis. Despite an underwhelming pattern of implementation and funding, there have
been a number of notable activities:
1. A grant by the ACL to provide a National APS Resource Center from 2011 to
2015.
2. A two-year pilot by ACL and the HHS Ofce of the Assistant Secretary for
Planning and Evaluation to design and test a National Adult Mistreatment
Reporting System.
3. Elder Abuse Prevention Intervention Grants made by ACL in FY 2012– FY
2015. The project evaluated replicable best practices in support of the develop-
ment of secondary and tertiary prevention and intervention strategies. Using the
results, AoA/ACL developed a resource for APS programs to use to improve
their programs.
4. AoA/ACL, in collaboration with Substance Abuse and Mental Health Services
Administration (SAMHSA), Centers for Disease Control (CDC), and the
National Institutes of Health/National Institution on Aging (NIH/NIA) to incor-
porate elder abuse screening into the CMS proposed rule on annual wellness
visits.
5. In 2013, CMS convened an Elder Mistreatment Symposium to revise existing
elder abuse measures and to make recommendations for elder abuse screening,
screening tools, and protocols for handling suspicions of elder abuse.
6. The Department of Justice’s Elder Justice Initiative (EJI) established the Elder
Justice Website as a resource for elder abuse prosecutors, researchers, practitio-
ners, and for victims of elder abuse and their families, as well as a forum for law
enforcement and elder justice policy communities to share information and
enhance public awareness on the subject matter. Also, the EJI collaborated with
DOJ’s Access to Justice Initiative and the Ofce of Victims of Crime to support
the development of online training for legal aid ofces to detect and address
elder abuse, neglect, and exploitation.
7. In July 2014, the Federal Trade Commission launched a new fraud education
campaign aimed at older people. The ‘Pass It On’ campaign is based on the
theory that older adults have agency and thus are part of the solution, not simply
the victims of scammers.
5 Elder Abuse Policy, Past, Present, andFuture Trends
58
8. DOJ, with support from ACL, created the Elder Justice Roadmap to set priorities
advancing elder justice by collecting information from 750 US stakeholders.
Going forward, sustained advocacy is crucial for the implementation of the
EJCC’s recommendations and continued action by federal government agencies.
Perhaps the most pressing task for advocates is to work with congressional support-
ers to pass legislation reauthorizing the EJA (Lindberg etal. 2011).
In the 115th Congress and the 116th Congress, there continues to be positive
momentum in the work to end elder abuse, neglect, and exploitation. The following
are some of the efforts.
5.4 Elder Abuse Prevention andProsecution Act of2017
Passage and signing of the bipartisan Elder Abuse Prevention and Prosecution Act
of 2017in October 2018 was a major milestone in the ght against elder abuse,
particularly elder nancial exploitation. This new law (P.L. 115-69 – S. 178)
enhances the federal government’s response to elder abuse and nancial exploita-
tion by sending a strong message that the Department of Justice will search for and
prosecute criminals to the full extent of the law. The bill was sponsored by Senate
Judiciary Committee Chairman Chuck Grassley (R-IA) and Sen. Richard Blumenthal
(D-CT), two long-time advocates for the rights of older adults.
Here are the provisions of the law from the Congressional Research Service:
5.4.1 Title I–Supporting Federal Cases Involving Elder Justice
(Sec. 101) This bill establishes requirements for the Department of Justice (DOJ)
with respect to investigating and prosecuting elder abuse crimes and enforcing elder
abuse laws. Specically, DOJ must:
• designate Elder Justice Coordinators in federal judicial districts and at DOJ,
• implement comprehensive training for Federal Bureau of Investigation agents,
and
• establish a working group to provide policy advice.
The Executive Ofce for United States Attorneys must operate a resource group
to assist prosecutors in pursuing elder abuse cases.
The Federal Trade Commission must designate an Elder Justice Coordinator
within its Bureau of Consumer Protection.
P. B. Teaster et al.
59
5.4.2 Title II–Improved Data Collection andFederal
Coordination
(Sec. 201) DOJ must establish best practices for data collection on elder abuse.
(Sec. 202) DOJ must collect and publish data on elder abuse cases and investiga-
tions. The HHS must provide for publication data on elder abuse cases referred to
APS.
5.4.3 Title III–Enhanced Victim Assistance toElder Abuse
Survivors
(Sec. 301) This section expresses the sense of the Senate that: (1) elder abuse
involves exploitation of potentially vulnerable individuals; (2) combatting elder
abuse requires support for victims and prevention; and (3) the Senate supports a
multipronged approach to prevent elder abuse, protect victims, and prosecute perpe-
trators of elder abuse crimes.
(Sec. 302) DOJ’s Ofce for Victims of Crime (OVC n.d.) must report to Congress
on the nature, extent, and amount of funding under the Victims of Crime Act of 1984
for older adultvictims of crime.
5.4.4 Title IV–Robert MATAVA Elder Abuse Prosecution act
of2017
Robert Matava Elder Abuse Prosecution Act of 2017 (Robert Matava experienced
nancial exploitation in Connecticut.)
This bill amends the federal criminal code to expand prohibited telemarketing
fraud to include ‘telemarketing or e-mail marketing’ fraud. It expands the denition
of telemarketing or e-mail marketing to include measures to induce investment for
nancial prot, participation in a business opportunity, or commitment to a loan.
A defendant convicted of telemarketing or e-mail marketing fraud that targets or
victimizes a person over age 55 is subject to an enhanced criminal penalty and man-
datory forfeiture.
The bill adds health care fraud to the list of fraud offenses subject to enhanced
penalties.
(Sec. 403) DOJ, in coordination with the EJCC, must provide information, train-
ing, and technical assistance to help states and local governments investigate, pros-
ecute, prevent, and mitigate the impact of elder abuse, exploitation, and neglect.
(Sec. 404) It grants congressional consent to states to enter into cooperative
agreements or compacts to promote and to enforce elder abuse laws. The State
5 Elder Abuse Policy, Past, Present, andFuture Trends
60
Justice Institute must submit legislative proposals to Congress to facilitate such
agreements and compacts.
5.4.5 Title V–Miscellaneous
(Sec. 501) This section amends Title XX (Block Grants to States for Social Services
and Elder Justice) of the Social Security Act to specify that HHS may award APS
demonstration grants to the highest courts of states to assess adult guardianship and
conservatorship proceedings and to implement necessary changes. The highest
court of a state that receives a demonstration grant must collaborate with the state’s
unit on aging and APSagency.
(Sec. 502) The Government Accountability Ofce (GAO) must review and report
on elder justice programs and initiatives in the federal criminal justice system. The
GAO must also report on: (1) federal government efforts to monitor the exploitation
of older adults in global drug trafcking schemes and criminal enterprises, the
incarceration of exploited older adults who are US citizens in foreign court systems,
and the total number of elder abuse cases pending in the US; and (2) the results of
federal government intervention with foreign ofcials on behalf of US citizens who
are elder abuse victims in international criminal enterprises.
(Sec. 503) DOJ must report to Congress on its outreach to state and local law
enforcement agencies on the process for collaborating with the federal government
to investigate and prosecute interstate and international elder nancial exploitation
cases.
(Sec. 504) DOJ must publish model power of attorney legislation for the purpose
of preventing elder abuse.
(Sec. 505) DOJ must publish best practices for improving guardianship proceed-
ings and model legislation related to guardianship proceedings for the purpose of
preventing elder abuse.
5.5 H.R.2639– Elder Justice Reauthorization Act
Representatives Peter King (R-NY, 2nd) and Suzanne Bonamici (D-OR, 1st) intro-
duced H.R. 2639 to reauthorize the EJA.The bill is considered a straight reauthori-
zation of the previous law that has expired. Plans for reintroduction in the 116th
Congress are underway in both the House and the Senate. King and Bonamici also
announced the establishment of a bipartisan Elder Justice Caucus in the US House
of Representatives. The caucus hopes to unify the elder justice voice in Congress by
bringing together members with a shared interest in preventing elder abuse.
The Senior Safe Act, which became law as part of S.2155, is designed to prevent
older adult nancial abuse by providing immunities for reporting under bank privacy
P. B. Teaster et al.
61
laws. The bills were sponsored by Reps. Kyrsten Sinema and Bruce Poliquin and
Sens. Susan Collins and Claire McCaskill.
H.R. 1457, the MOBILE Act, which also became law as part of S.2155, autho-
rizes a national standard for banks to scan and retain information from driver’s
licenses and identity cards as part of a customer online onboarding process, via
smartphone or website. The House version was sponsored by Reps. Scott Tipton
and Terri Sewell, and the Senate version was sponsored by Senator Tim Scott.
The RAISE Family Caregivers Act, which became law as PL 115-119, directs
HHS to develop and make publicly available a National Family Caregiving Strategy
that identies recommended actions for recognizing and supporting family caregiv-
ers, and creates a Family Caregiving Advisory Council to advise the department on
recognizing and supporting family caregivers.
The Grandparents Raising Grandchildren Act, which became law as PL 115-
196, establishing an Advisory Council to Support Grandparents Raising
Grandchildren. The Council must identify, promote, coordinate, and publicly dis-
seminate information and resources to help older relatives meet the needs of the
children in their care and maintain their own health and emotional well-being.
The BOLD Act, which became law, amended the Public Health Service Act to
award cooperative agreements: (1) for the establishment or support of national or
regional centers of excellence in public health practice in Alzheimer’s disease; (2)
to state public health departments, Native American tribes, and other entities to
promote cognitive functioning, address cognitive impairment and unique aspects of
Alzheimer’s disease, and help meet the needs of caregivers; and(3) for analysis and
public reporting of data on the state and national levels regarding cognitive decline,
caregiving, and health disparities, and monitoring of objectives on dementia and
caregiving in the Department of Health and Human Services’ Healthy People 2020
report.
Passage in the House (but not in the Senate) in the 115th Congress of authoriza-
tion of the Geriatric Workforce Enhancement Program (GWEP) (S.2888,
H.R.3713, H.R.3728) is abipartisan bill that wouldprioritize funding for primary
care geriatric workforce programs that integrate competencies of elder abuse.
H.R. 3728, the Educating Medical Professionals and Optimizing Workforce
Efciency Readiness (EMPOWER) Act, sponsored by Reps. Michael Burgess
(TX), Jan Schakowsky (IL) and Larry Bucshon (IN), passed the House by voice
vote but was not enacted into law.
• Introduced in the Senate and House was the Stamp Out Elder Abuse Act. Bill
sponsors included Senators Susan Collins, Claire McCaskill, and Amy Klobuchar
and Representatives Peter King, Carolyn Maloney, Suzanne Bonamici, and Jan
Schakowsky. The bill wouldcreate a semi-postal stamp (also known as a ‘charity
stamp’) to provide additional funding to the federal government for programs to
address elder abuse, neglect, and exploitation. The bill sponsors have plans to
re-introduce it in the 116th Congress.
• The Senate Special Committee on Aging has been working for more than a year
on hearings, a report, and legislation to address the many problems that have
5 Elder Abuse Policy, Past, Present, andFuture Trends
62
become well-known with guardianships. Senators Collins and Casey have intro-
duced the Guardianship Accountability Act of 2019, which focuses on three
key areas that should be addressed: oversight of guardians and guardianship
arrangements, alternatives to guardianship and restoration of rights, and the need
for better data.
5.6 Funding Challenges
The ongoing priority of advocacy groups like the Elder Justice Coalition is to secure
appropriations for the programs that Congress has authorized through the EJA the
Older Americans Act, SSBG, and other programs that help prevent or address elder
abuse, neglect, and exploitation. To date, a total of $58 million in direct funding for
EJA programs, such as the Elder Justice Initiative, has been secured.
• Congress gave the Elder Justice Initiative a $2 million increase for FY 2018,
bringing it to a funding level of $12 million for FY 2018 and again in FY 2019.
• Other programs related to elder justice included $1.7 billion for the SSBG, $21.7
million for the Long-Term Care Ombudsman program (and elder abuse preven-
tion in Title VII of the OAA), and $3.9 million for Elder Rights Support Activities
• At the December 6 meeting of the Elder Justice Coordinating Council, the DOJ,
represented by Antoinette (Toni) Bacon, who serves as the National Elder Justice
Coordinator and Associate Deputy Attorney General, announced that the DOJ is
increasing resources to elder abuse victims. Their Ofce for Victims of Crime
will provide nearly $18 million to help older adults who are victims of crime.
• Funding for 15 separate grant awards related to elder justice were also announced
in the Fall of 2018 by ACL.One award is for the Orutsararmiut Native Council
in Bethel, Alaska, for a two-year project that aims to reduce harm and maltreat-
ment among Yup’ik Eskimo elders. Also, 14 states received grants to enhance
statewide APS systems, evaluate and improve practices, and improve data collec-
tion and reporting to ACL’s National Adult Maltreatment Reporting System.
These funds and programs are critically important to the older Americans they
serve. Unfortunately, they only address a small number of the millions of older
adults who are abused and exploited each year.
5.7 The Older Americans Act
The Older Americans Act (1965) (OAA) was the rst federal law to provide com-
prehensive services for older adults without means testing. Its passage was a tri-
umph for the new elds of gerontology and geriatrics. Based on a model of active
aging (Atchley 1989), the OAA created the National Aging Network, composed of
the AoA (incorporated in 2012 into the Administration for Community Living)
P. B. Teaster et al.
63
(federal level), State Units on Aging (state level), and Area Agencies on Aging
(local level). Like many federal programs, the OAA must be continually reautho-
rized by Congress, and funding for it consistently fails to meet OAA aspirations and
mandates. To address funding shortfalls, services are increasingly targeted to spe-
cic groups of older adults. In general, the OAA funds nutrition and supportive
home and community-based services, disease prevention/health promotion services,
training for employment, the National Family Caregiver Support Program and the
Native American Caregiver Support Program, and elder rights programs (Title VII
or the Vulnerable Elder Rights Protection Title). Title VII strengthens and coordi-
nates the LTC Ombudsman (LTCO) Program; Programs for the Prevention of
Abuse, Neglect and Exploitation; State Legal Assistance Development Programs;
and Native American Organization and Elder Justice. Actually, all titles of the Act
address elder abuse in one way or another (ACL 2017).
Since its establishment in the 1970s, the LTCO program has played a major role
in identifying and addressing abuse, neglect, and exploitation of residents of nursing
homes, board and care, and assisted living facilities. Long-term care ombudsmen
advocate for residents of nursing homes, board and care homes, and assisted living
facilities. The National Association of State Long-Term Care Ombudsman Programs
(NASOP) has been advocating for several years for a $20 million appropriations
specically to support additional ombudsmen to address assisted living facilities
quality concerns in particular. The total funding under Title VII for the LTCOP is
only $17.784 million for FY 2019.
Ombudsmen educate consumers about making informed choices and how to get
quality care as well as assist consumers with resolving complaints. Every state is
required to have a LTCO program. In 2016, the program included the provision of
services by 7331 volunteers certied to handle complaints and more than 1100 paid
staff. For every one staff ombudsman, about six volunteer ombudsmen serve resi-
dents. In 2016, ombudsman staff and volunteers investigated 199,493 complaints
made by 129,559 individuals. Ombudsmen were able to resolve or partially resolve
74%– or three out of every four complaints investigated. In January 2015, AoA
published historic nal federal regulations for the long-term care ombudsman
(LTCO) program.
Also through the OAA, ACL supports the National Long-Term Care Ombudsman
Resource Center and the National Center on Elder Abuse (NCEA), which subcon-
tracts with partner organizations to implement its mission. The NCEA serves as a
national resource center dedicated to the prevention of elder abuse. It offers a
resource database of research and education and training materials related to elder
abuse (ACL 2017).
5 Elder Abuse Policy, Past, Present, andFuture Trends
64
5.8 Violence Against Women Act
In 1994, Congress passed the Violence Against Women Act (VAWA) in recognition
of the severity of crimes associated with domestic violence, sexual assault, and
stalking. Though criminal victimization of older women is generally declining
(Ofce of Justice Programs 1994), older adults are less likely to report crime and
more likely to sustain lasting (and sometimes fatal) injuries than their younger
counterparts (DOJ 2019). The Ofce on Violence Against Women (OVW) was cre-
ated to implement VAWA(Violence Against Women Act 2016). In 2002, legislation
made the OVW a permanent part of the Department of Justice with a presidentially-
appointed, senate-conrmed director. OVW administers nancial and technical
assistance to communities across the country that are developing programs, poli-
cies, and practices aimed at ending domestic violence, dating violence, sexual
assault, and stalking. Currently, OVW administers 4 formula-based and 20 discre-
tionary grant programs. The four formula programs include the following: STOP
(Services, Training, Ofcers, Prosecutors), SASP (Sexual Assault Services
Program), State Coalitions, and Tribal Coalitions. By forging state, local, and tribal
partnerships among police, prosecutors, judges, victim advocates, health care pro-
viders, faith leaders, and others, OVW grant programs help provide victims with the
necessary protections and services required for the pursuit of safe and healthy lives,
while simultaneously enabling communities to hold offenders accountable for their
violence. The section of the VAWA that addresses strengthening the health care
system’s response to domestic violence includes grants for elder abuse and the
development of training modules and policies that address the overlap of elder
abuse, domestic violence, child abuse, and other violence. With VAWA operating
under current authorization, the main challenge for advocates is to press for ade-
quate funding for implementation of its programs and to collaborate with providers
of services to victims of domestic violence to ensure that they are equipped to meet
the particular needs of victims of late-life domestic violence (Late Life Domestic
Violence 2006).
5.9 Major International Efforts toAddress Elder Abuse
While a number of notable accomplishments to address the issue of elder abuse
have taken hold in the US, international efforts to address the problem are running
somewhat parallel and sometimes,are more comprehensive. Rather than address the
problem from the theoretical vantage of social work, medicine, or law, the problem
is couched internationally as one of human rights.
P. B. Teaster et al.
65
5.10 Universal Declaration ofHuman Rights (1948)
The Universal Declaration of Human Rights (UDHR) is a landmark human rights
document that resulted from the necessity to declare fundamental human rights in
the wake of the atrocities occurring in the two world wars. The UDHR was drafted
by individual representatives from diverse countries and cultures around the world
and was ratied by the United Nations General Assembly in 1948; it was signed by
48 countries. Translated into more than 500 languages (the most translated docu-
ment in the world), it proclaims fundamental human rights deserving universal pro-
tection (United Nations n.d.). Its preamble sets the stage for the individual
declarations:
Whereas recognition of the inherent dignity and of the equal and inalienable rights of all
members of the human family is the foundation of freedom, justice, and peace in the world.
The UDHR contains 30 articles outlining fundamental human rights principles
and the importance of nations to bind together to promote them.
All human beings are born free and equal in dignity and rights. They are endowed with
reason and conscience and should act towards one another in a spirit of brotherhood.
(Article 1).
Moreover, everyone has the right to life, liberty, and security of person (Article
3), should not be slaves (Article 4), and should not be subject to torture or inhuman
punishment (Article 4). People should not be arbitrarily discriminated against
(Article 8), imprisoned (Article 9) or moved, and should have due process in crimi-
nal proceedings (Articles 10–13). People have rights to their nationality and to free
association (Articles 14–17). In addition, people have the right to have freedom of
thought, expression, worship, and belief (Articles 18–20). Articles 21–24 declare
the importance of involvement in government, resources, work, and equal pay for
equal work. Articles 25–27 address the rights of individuals to be free from basic
want (e.g., food, housing, shelter, medical care, social services) and to be educated.
Finally, Articles 28–30 attest to the permanency and support that states should give
to upholding the Articles and UDHR as a whole. The US is the only industrialized
country that has failed to ratify the UDHR (United Nations n.d.).
5.11 United Nations Principles forOlder Persons (1991)
The UN Principles for Older People were adopted by a UN General Assembly in
1991, undergirded by the recognition that older persons contribute to their societies
and are reaching advanced age in greater and unprecedented numbers worldwide.
Like the UDHR, the document emphasizes human rights, the worth and dignity of
human persons, and the equality of men and women. In particular, the UN Principles
include the broad categories of independence, participation, care, and
self-fulllment.
5 Elder Abuse Policy, Past, Present, andFuture Trends
66
Under the category of independence, older adults should have access to adequate
food, water, shelter, clothing and health care; the opportunity to work; to participate
and choose when to exit the labour force; appropriate education and training pro-
grams, safe and adaptable living environments; and the ability to remain in their
homes as long as possible. Under participation, older adults should remain inte-
grated into society, have opportunities for service in the community, and be free to
form movements or associations. Under the topic of care, older people should have
family and community care in accordance with their society’s culture, have access
to health care, have access to social and legal services, be free to make use of appro-
priate levels of care in facilities, and enjoy human rights and freedoms wherever
they reside with their dignity respected. Under the topic of self-fulllment, older
people should be able to pursue opportunities in numerous spheres to pursue their
potential. Finally, under dignity, older peopleshould live in dignity and security and
be free of exploitation and physical or mental abuse. They have the right to be
treated fairly and valued independently.
5.12 The Madrid International Plan ofAction onAgeing
(2002)
The monumental Madrid International Plan of Action on Ageing (MIPAA) and the
Political Declaration, adopted at the Second World Assembly on Ageing (UN 2002),
emphasized how the present and future world should address a ‘society for all ages.’
Its three priorities are older persons and development, advancing health and well-
being into old age, and ensuring enabling and supportive environments. The MIPAA
was intended to be:
…a resource for policymaking, suggesting ways for Governments, non-governmental orga-
nizations, and other actors to reorient the ways in which their societies perceive, interact
with and care for their older citizens.
The plan represents the rst time governments agreed to link questions of ageing
to other frameworks for social and economic development and human rights and
links with previous United Nations conferences and summits.
Most pertinent to elder abuse is Priority Direction II, Advancing health and well-
being into old age, and Priority Direction III, Ensuring enabling and supportive
environments. Under Priority Direction II, the MIPAA stresses physical and mental
health and ways to achieve it: health and well-being throughout an older person’s
life (Issue 1), Universal and equal access to health-care services (Issue 2), Older
persons and HIV/AIDS (Issue 3), Training of care providers and health profession-
als (Issue 4), Mental health needs of older persons (Issue 5), and Older persons and
disabilities (Issue 6). Under Priority Direction III, the MIPAA stresses enabling and
enhancing social environments: Housing and the living environment (Issue 1), care
and support for caregivers (Issue 2), Neglect, abuse, and violence (Issue 3); and
images of ageing (Issue 4). Specic to Issue 3, the MIPAA stresses the elimination
P. B. Teaster et al.
67
of all forms of neglect, abuse, and violence of older persons (Objective 1). That
older women are the especial victims of abuse is highlighted within the section as
well as how often older women live in poverty and without legal protection, leaving
them unable to participate in their own decision making and vulnerable to abuse.
Actions to address the problem of elder abuse include education of professionals
and the general public, especially through use of the media; the abolition of harmful
widowhood rites; strengthening legislation to eliminate the problem; eliminating
harmful traditional practices involving older adults; encouraging efforts of govern-
ment and non-governmental organizations to address the problem; minimizing risks
and vulnerabilities of older women; and encouraging research in order to under-
stand the problem and its sequelae.
Objective 2, the creation of support services to address elder abuse, includes ve
action steps. The MIPAA recommends establishing services for victims of abuse,
encouraging professionals to report abuse when it is suspected, encouraging profes-
sionals to inform older persons who are suffering from abuse about services avail-
able to them, including information on elder abuse in training of people in caring
professions, and creating informational programmes educating the older people
themselves about elder nancial exploitation.
According to Zaidi (2018), despite both promise and progress, implementation is
highly uneven due to resources, political will, and reliable data. Although one prob-
lem is lack of age-disaggregated data in many countries, Zaidi stresses that the pri-
mary problem is that the MIPAA monitoring toolkit was improperly developed.
Thus, monitoring, when conducted, was not uniform and not well associated
between efforts and policy development, implementation, and evaluation. Zaidi
suggested the development of a dashboard of indicators harmonized with key priori-
ties of the MIPAA.
5.13 Open-Ended Working Group onAgeing
The Open-Ended Working Group on Ageing was established by the General
Assembly by Resolution 65/128 on 21 December 2010. The working group has
focused on the existing framework of the human rights of older persons and the
identication of gaps and solutions to address them. One possibility is for the work
to lead further instruments or measure, such as a convention on the rights of older
persons. Below are highlights from the American Bar Association (ABA)Commission
on Law and Aging on activities related to the Open-Ended Working Group on
Ageing in 2015.
5 Elder Abuse Policy, Past, Present, andFuture Trends
68
5.14 ‘2015 WasaBig Year forInternational Progress’
In 2015, the Commission continued to participate in the annual meetings of the UN
Open-Ended Working Group on Ageing in support of the new ABA Liaison
Professor Bill Mock of John Marshall Law School. The Working Group continued
to engage in extensive inquiry and debate about whether the UN should pursue a
separate convention on the rights of older persons, or instead seek to strengthen the
enforcement of existing international normative standards as they may apply to
older persons. That question remains a threshold sticking point to consensus.
The European Union, the US, Canada, Australia, and Japan are opposed to draft-
ing such a convention, while the vast majority of low and middle income countries
are strongly in favor. High income industrialized countries claim that the existing
legal instruments (such as the Convention on Economic, Social and Cultural Rights,
for instance) apply to all people, including older persons, and are sufcient. Gaps
arise because governments fail to implement the relevant conventions. Countries
supporting a specialized convention, as well as nearly every non-governmental
organization that has addressed the Working Group, claim that, since the existing
instruments do not identify older persons as such, the instruments are too non-
specic, fragmented, and vague in their application to older persons. As a result, this
demographic group ‘falls between the policy cracks.’ Moreover, without the explicit
international legal protection conferred by a convention, older persons remain vul-
nerable to poverty, abuse, neglect, illness, and premature mortality.
The ABA Commissionand the Working Group have spoken in favor of initiating
work on a convention. They have collaborated with the John Marshall Law School
and Roosevelt University in distributing a model international convention, referred
to as the Chicago Declaration. The model is an evolving work, based on continuing
input from experts and stakeholders internationally, including the ABA Commission.
The hope is that this declaration will concretize thinking about the organization and
a future convention.
On the regional level, the movement toward an inter-American convention
achieved a milestone. On June 15, 2015, the General Assembly of the Organization
of American States (OAS) adopted the Inter-American Convention on Protecting
the Human Rights of Older Persons. Outgoing Commissioner Marcos Acle and
rst-year Commissioner Ivan Chanis were both directly involved in the process in
their professional roles at the OAS.The convention represents a major step forward
in addressing the human rights needs of older persons. The instrument was immedi-
ately signed by governments of Argentina, Brazil, Chile, Costa Rica, and Uruguay
at OAS headquarters in Washington, DC.For the convention to enter into force, at
least two signatory countries must not only sign it but also they must ratify it.
The purpose of the convention—the rst regional instrument of its kind in the
world—is to promote, protect, and ensure the recognition and the full enjoyment
and exercise, on an equal basis, of all human rights and fundamental freedoms of
older persons in order to contribute to their full inclusion, integration and participa-
tion in society. The starting point of the convention is the recognition that all existing
P. B. Teaster et al.
69
human rights and fundamental freedoms apply to older people and that they should
fully enjoy them on an equal basis with other segments of the population. The
Convention will strengthen the legal obligations to respect, promote, and ensure the
human rights of older persons. Its ratication will carry the obligation of States’
parties to adopt measures to guarantee a differentiated and preferential treatment to
older persons in all spheres.
Not surprisingly, the US has not been a supporter of the OAS convention or of
the proposal for a UN convention. The US prides itself on its commitment and inno-
vation in protecting the rights and quality of life of older Americans. Historically,
the US has been reluctant to allow itself to be subject to any laws or rules created
and enforced by non-U.S. authorities. Nevertheless, treaties or conventions widely
adopted by other nations tend to affect legal thinking and analysis occurring in
American law—and sometimes in profound ways (Bifocal 2018.)
As the ABA article mentions, the Chicago Declaration on the Rights of Older
Persons provided a document that offered participants a vision of what a convention
on the rights of older persons could be. The Chicago Declaration was introduced at
a side event where it was shared as a working product of scholars, advocates, and
policy makers from more than a dozen countries. The document was built upon the
foundation of previous international human rights instruments and regional and
international instruments promoting the rights of older persons. The Open-Ended
Working Group continues its activities with the Tenth Working Session in April
2019.
5.15 Conclusion
Efforts to address the problem of elder abuse were slow to capture public attention.
Advocacy in the late 1940s and early 1950s had its genesis in the atrocities of the
recent world wars and a concerted effort, both in the US and internationally, to pre-
vent them from happening again. The issue of elder abuse was rst regarded as a
private, family problem for which large-scale prevention and intervention efforts
were deemed inappropriate. However, at the local level and on the scale of govern-
ments, the tide of opinion was turning such that over time the issue became one that
emerged as a public sphere problem, one that affects all of society (arealization
thatis continuing to evolve to this day).When public awareness impelled the issue
into the political and public sphere (through notable efforts of advocates and politi-
cians alike), more and more inuential sectors of action (e.g., healthcare, law,
nance) became involved in efforts to prevent the problem from happening and to
intervene more appropriately and with adequate resources when it did.
Another understanding critical to action was the realization that the problem
affected people of all ages. When the problem became one forall generations,
efforts related to its discovery and prevention began to take hold on a greater scale
(the 1995 WHCoA was particularly notable as a U.S. example).
5 Elder Abuse Policy, Past, Present, andFuture Trends
70
Internationally, the issue of human rights was emerging, and so was the dawning
understanding that human rights should be extended to more and more groups of
people around the world and that social and economic status had much to do with
impeding the exercise of human rights for all. The international documents, the
UNDHR, the UNPOP, and the MIPAA all expanded the human rights theme. The
extension and focus of those rights were rst on children and werelater broadened
to older adults. However, it was not until 1992 that a major international document
on human rights included a section specically addressing elder abuse. Although
much is being done to connect thehuman rights of older persons around the world,
much work remains to be done to crystallize aspirational laws and declarations and
parlay them into (measurable) action and outcomes, as the work of the Open Ended
Working Group on Aging attests.
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5 Elder Abuse Policy, Past, Present, andFuture Trends
73© Springer Nature Switzerland AG 2020
A. Phelan (ed.), Advances in Elder Abuse Research, International Perspectives
on Aging 24, https://doi.org/10.1007/978-3-030-25093-5_6
Chapter 6
‘If YouDo Not Believe That It Happens
YouWon’t See It Either!’-Sexual Abuse
inLater Life
WencheMalmedal
6.1 Introduction
Sexual abuse is one of the categories of elder abuse and dened as ‘nonconsenting
sexual contact of any kind’ (Teaster and Roberto 2004a). Attention was rst drawn
to this type of abuse during the 1990s (Ramsey-Klawsnik 1991; Holt 1993; Bennett
and Kingston 2013). One of the rst studies on sexual abuse in later life was con-
ducted by Ramsey-Klawsnik (1991), and in 1999, a conference under the title “The
Great Taboo” was organized by Action on Elder Abuse, a charitable organization in
the United Kingdom. Because of the hidden nature of late life sexual abuse and the
difculties in obtaining data on the topic, a paucity of research exists from domestic
as well as institutional settings and there is still a gap in knowledge around older
victims of sexual abuse. Single reported acts from media and court systems demon-
strate that age is no protection against sexual victimization, either in community
dwelling older adults or for nursing home residents, but this problem has not gained
much attention in research. However, recently several studies have addressed the
issue (Burgess etal. 2008, Malmedal et al. 2015, Rosay and Mulford 2017, Alon
etal. 2018). Professionals in health care and social welfare systems are in key posi-
tions to be able to identify and detect sexual abuse. Nevertheless, it is likely that
they do not have the necessary knowledge about this taboo topic. This chapter will
help professionals in identifying sexual elder abuse, as well as providing them with
relevant knowledge about how to deal with such cases.
W. Malmedal (*)
Department of Public Health and Nursing, Norwegian University of Science and Technology
(NTNU), Trondheim, Norway
e-mail: wenche.k.malmedal@ntnu.no
74
6.2 Dening theIssue
An older adult can be exposed to sexual abuse from a stranger or acquaintance, a
spouse/partner, a child, a grandchild or other relatives, a care provider, or a co-
resident (in residential care facilities).
Sexual abuse dened as “nonconsenting sexual contact of any kind” is said to be
the most hidden form of elder abuse (Teaster and Roberto 2004a, b) and is the least
acknowledged and reported type of elder mistreatment. Sexual abuse takes several
forms; some include physical contact, and others do not. Sexual abuse can include
threat or coercion to participate in a sexual activity. This can range from being
exposed to aggressive obscenities and behavior, being forced to watch porn to con-
summated rape. The denition of sexual abuse includes (but is not limited to)
unwanted touching and all types of sexual assault or battery, such as rape, sodomy,
coerced nudity, and sexually explicit photographing (National Centre on Elder
Abuse n.d.). Sexual contact with any person incapable of giving consent is also
considered sexual abuse.
In most of the literature on elder abuse, sexual abuse is a main category along
with physical, psychological, nancial abuse, and neglect. Some studies, however,
categorize sexual abuse as a subcategory of physical abuse, which makes it even
more difcult to estimate the prevalence. According to the World Health Organization,
sexual well-being is a part of a person’s global well-being (WHO 2006). Sexual
activity is acknowledged as an important part of relationships in late life, and older
persons with active sex lives are reported to have higher life satisfaction (Hodson
and Skeen 1994). The problem faced by professionals is the question of the older
person’s consent when there are challenges in decision-making capacity, in addition
to the concerns raised by relatives. Sexual activity among nursing home residents
may be unproblematic for the residents themselves if both are able to consent, but
the relatives may experience this as extremely problematic. Assessing sexual con-
sent capacity is challenging and complex, but if sexual activity among cognitively
impaired older persons is occurring, the capacity of both should be assessed and
documented (Rosen etal. 2010). The professionals facing these issues need to bal-
ance the wish to support the sexual rights of the older person and the awareness that
sexual activity may be non-consensual and thus regarded as sexual abuse.
6.3 How Often Does It Happen?
On global basis, there is no ofcial prevalence statistics on the sexual abuse of older
persons. A systematic review on elder abuse in community population identied a
lack of consistency in denitions of elder abuse (Dong 2015) and some studies clas-
sify sexual abuse as a subcategory of abuse while others label it under physical
W. Malmedal
75
abuse. In addition, since the number and content of the questions used in the studies
varies, as well as differences in how the calculation is done, comparing the different
studies does not make much sense. Pillemer et al. (2016) conducted a scoping
review on elder abuse and found that researchers generally developed their own set
of questions to screen for elder sexual abuse. Studies consistently operationalized
sexual abuse cases as one or more events occurring in a given time period.
Despite methodological and denitional challenges, the results from studies con-
ducted prove the presence of elder sexual abuse. Most of the studies are conducted
in community dwelling settings. Studies in residential care settings are rarer when
comes to research in elder abuse, including sexual abuse. Pillemer etal. (2016)
found in a scoping review that elder sexual abuse 1-year prevalence ranged from
0.04% to 0.8%, with a mean of 0.7%. Prevalence survey reports from United
Kingdom and Ireland show that 0.3% had experienced one or more instances of
sexual abuse since the age of 65 (O’Keeffe etal. 2007, Naughton etal. 2010) and a
prevalence study conducted in the United States (US) shows that 0.6% of older
persons are exposed to sexual abuse (Acierno etal. 2010). A study from a district in
Sweden (Kristensen and Lindell 2013) reports that 2.2% of females and 1.2% of
males had been exposed to sexual abuse after the age of 65years. A national preva-
lence study on abuse among community dwelling older adults in Norway (Sandmoe
etal. 2017) included sexual abuse in the questionnaire and found that 1.4% of the
older adults had experienced this form of abuse after the age of 65years while 0.5%
had experienced this the last 12months.
The review conducted by Pillemer etal. (2016:195) did not cover elder abuse
prevalence in institutional settings because of the general lack of research in this
environment, stating ‘No reliable prevalence studies have been conducted of such
mistreatment in nursing homes or other long-term care facilities.’ However, a few
studies have investigated sexual abuse in residential care facilities, such as nursing
homes and the results indicate the incidence of sexual abuse of older people
(Drennan etal. 2012; Yon etal. 2018). Rosen etal. (2010) state that even though no
studies were found that had systematically examined the prevalence of sexual abuse
in long-term care facilities, sexual aggression and sexual abuse occur, with fellow
residents as the most common perpetrators. An extensive literature review con-
ducted by Malmedal etal. (2015) shows similar ndings, however, none of the stud-
ies included in the review referred to prevalence studies. Rather, the studies
examined related to cases of abuse reported to Adult Protective Service or referrals
to the court system, all from United States. The Irish nursing home study (Drennan
etal. 2012) found a low rate of sexual abuse perpetration. Nine (0.7%) of the 1241
staff had observed a colleague talking to or touching a resident in a sexually inap-
propriate manner, while three (0.2%) of the respondents admitted that they them-
selves had spoken to or touched a resident in a sexually inappropriate manner. In
Norway, a few pilot studies have revealed that the phenomenon is present in nursing
homes, but the true extent is not yet known, due to the lack of larger prevalence
studies (Iversen etal. 2015; Malmedal etal. 2016).
6 ‘If YouDo Not Believe That It Happens YouWon’t See It Either!’-Sexual Abuse…
76
6.4 Risk Factors andWarning Signs
Age is not per se a risk factor, but even though older adults are mostly healthy and
independent, age-related illnesses may increase the risk for sexual abuse. Cognitive
impairments, like Alzheimer’s disease and other types of dementia, are found to be
risk factors for sexual abuse (Burgess etal. 2000a, b; Teaster and Roberto 2004a).
Self-care limitations enhance the dependency and vulnerability of the older person
and may increase the risk of being abused in any form including sexual abuse
(Teaster and Roberto 2004a). Self-care limitations may be caused by physical or
cognitive impairments. Research suggest that victims of elder sexual abuse are
likely to be cognitively and/or physically impaired (Rosen etal. 2010) and depen-
dency might set up the dynamic for potential abuse (Teitelman 2006). Sexual abuse
in old age is directed primarily against women (Teaster and Roberto 2004a;
Abramsky etal. 2011), regardless of setting. A factor contributing to sexual vio-
lence against women in domestic settings may be the coercive control exhibited by
an abusive husband (Ramsey-Klawsnik 2004). This abuse may have been going on
for many years and the domestic violence has simply “grown old”. A literature
review (Malmedal etal. 2015) found that both men and women are victims of nurs-
ing home sexual abuse, but in the majority of cases reported, women constituted the
victims. The World Health Organization (WHO) (2002) states that ofcial statistics
vastly underrepresent male victims of sexual abuse, and this seems to be the case
also for elder abuse. Furthermore, Malmedal etal. (2015) shows that most victims
of sexual abuse in nursing homes were cognitively impaired (dementia, stroke, and
brain injury), had a psychiatric diagnosis and/or were physically frail (wheelchair,
bedridden, paralyzed, and reduced mobility), and had somatic illnesses. Regardless
of gender, the older residents (age 79–99years) were more at risk of sexual abuse.
This could support the view that other factors apart from gender are more important
in the oldest age group. This is also underlined in the WHO report (WHO 2002),
where it is, based on community-based prevalence studies, concluded that older
men are at risk of abuse by spouses, adult children, and other relatives in about the
same proportion as women.
A particularly high-risk group is that of homeless or marginally housed older
people. Little is known about sexual assault against older persons who are home-
less. We do not know whether the risk for sexual abuse is higher among older home-
less persons, than other older populations, but ndings suggest that this phenomenon
also occurs in this group, and that these older women are more likely to be sexually
assaulted than men (Dietz and Wright 2005).
Signs and indicators of sexual abuse against older adults can be either behavioral
or physical. They include the following:
• Bruises around the breasts or genital area or inner thigh
• Unexplained venereal disease or genital infections
• Unexplained vaginal or anal bleeding
• Irritation or pain of the anus or genitals
• Difculty in walking, standing or sitting
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• Marked changes in behaviour
• Torn, stained, or bloody underclothing
• An older person telling you they have been sexually assaulted or raped
• Panic attacks
• Signs of Post-Traumatic Stress Disorder (PTSD)
• Symptoms of agitation
• Social or emotional withdrawal from others
• Engaging in inappropriate, unusual or aggressive sexual activities
• Suicide attempts
• Engaging in unusual or inappropriate actions that appear to be from a sex role
relationship between the perpetrator of elder sexual abuse and the victim. (Action
on Elder Abuse (n.d.), Nursing Home Abuse Centre (n.d.))
It is important to be familiar with the different forensic markers, signs and symp-
toms that indicate elder sexual abuse. It is also important to be responsive to any
verbal or nonverbal disclosure from the older person. It might not be that they are
using direct language to disclose sexual abuse, but may ‘beat around the bush’,
directly avoiding naming the abuse but trying to disclose. Shame and embarrass-
ment is not cited in the list above, but victims of elder sexual abuse experience
shame and embarrassment, as do younger victims, and this reduces the likelihood of
disclosure of the abuse (Teitelman 2006).
6.5 Who Are theOffenders?
Within family settings, the offender may be an acquaintance or a friend, stranger,
spouse or partner, other relative, or service provider (Baker et al. 2009). In the
majority of the cases, it seems that current or former spouses or partners are the
offender, but adult children, grandchildren and other relatives may also sexually
abuse their older relatives (Ramsey-Klawsnik 2004; Roberto and Teaster 2005;
Bonomi etal. 2007).
In institutions, residents are mainly sexually abused by co-residents or staff
members (Ramsey-Klawsnik etal. 2007; Rosen et al. 2010; Iversen etal. 2015).
Co-residents identied as offenders of elder sexual abuse are characterized by hav-
ing some psychopathology such as psychiatric illnesses or dementia and/or alcohol/
drug abuse. Some may have criminal histories, including sexual assault convictions
(Teaster etal. 2007). Hypersexual behaviors, which are not uncommon in cogni-
tively impaired persons, are a potential risk factor for sexual aggression towards
co-residents. Hypersexual behavior may also occur due to medication for certain
diseases, such as Parkinson (Rosen etal. 2010). Such behaviors include masturbat-
ing in the presence of others, touching others in inappropriate ways, and talking to
others in a sexually inappropriate manner.
In a study on convicted perpetrators in 52 cases of sexual abuse against older
persons (Jeary 2005), around one-third of the perpetrators were motivated primarily
6 ‘If YouDo Not Believe That It Happens YouWon’t See It Either!’-Sexual Abuse…
78
by sexual gratication. The age range of the offenders was 16–70+ years. Perpetrators
reported that they were sexually attracted by older persons, and liked to masturbate
while watching ‘granny porn’. The concept “gerontophilia” is not well researched,
but is described as a specic sexual inclination towards older persons and may at
times explain the sadistic attacks made upon them (Kaul and Duffy 1991). According
to Burgess etal. (2000b) gerontophiliacs represent a group of assailants who often
look for employment in nursing homes where they can have access to older
people.
It is also important for professionals to acknowledge that even though there can
be a gender aspect to the sexual abuse of older people where alleged and suspected
offenders are mainly men, and the victims are mainly woman, one must be aware of
the possibility for men to be abused by women and same sex abuse (Iversen etal.
2015).
6.6 Why Is It Still aHidden Problem?
Societal ignorance and disbelief regarding elder sexual abuse may play an important
role why cases are not detected and that the victims are not receiving appropriate
and early intervention. Sexual abuse of older adults is still not recognized as a social
problem in many countries, and along with the general lack of mandatory reporting
systems, this problem is often hidden and not acknowledged among professionals or
in society. Some countries and states do have mandatory reporting of elder abuse
cases, but even where this exists, health care providers are not always aware of the
mandatory reporting laws or how to enforce those (Hirst etal. 2016).
Health professionals and social workers play an important role in identifying
elder abuse cases, including sexual abuse, and the lack of awareness of the abuse
may leave the problem unsolved for the older person. Professionals working with
older persons may not have enough knowledge to detect, investigate and initiate
actions to help the older victim. It is easy for them to believe that what they observe
may be a consequence of old age, rather than an abusive act. Studies with staff in
Norwegian nursing homes revealed that they had very little knowledge of the phe-
nomena, and that they were not aware of how to act if they identied cases of sexual
abuse at their workplace (Iversen etal. 2015; Malmedal etal. 2016). A study among
nursing home staff (Iversen etal. 2015) shows that sexual abuse of older residents
is still a taboo topic. Acts of sexual abuse are difcult to imagine; it is hard to
believe that it occurs. The fact that staff are not aware that it could happen, or have
a hard time believing that it actually happens, can amplify the residents’ vulnerable
position as potential victims of abuse, and it makes it even more challenging to
report or uncover such acts. Within families, it may be even harder to believe that a
son is capable of raping his mother, or that someone close will take sexual advan-
tage of a frail older person with physical or mental disabilities. The societal and
professional disbelief may be rooted in ageism. Older persons are seen as non-
sexual individuals and it is therefore hard to imagine that sexual abuse against older
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79
residents happens (Iversen etal. 2015). A common stereotype perception is that
sexuality and older people is a non-entity, in other words older people are not inter-
ested in sexuality. This view is supported by an extensive literature review showing
that older people experience a tension between the desire to express their sexuality
and social conventions that inhibit them from doing so (Gewirtz-Meydan et al.
2018). Connolly etal. (2012) suggest that by not having knowledge of sexuality
related to older persons and of sexual abuse against older persons, we are undermin-
ing their health, safety, and well-being. There are also occasions when sexual abuse
or assault is reported but is not taken seriously because of the victim’s age or
assumptions about their mental capabilities.
It is important that professionals understand the challenges in disclosing elder
sexual abuse. The older person him/herself may be unable to report, due to lack of
physical or mental capacity. They may also be dependent on the abuser for care and
basic needs and fear punishment if they tell someone about the abuse. In addition,
the feeling of shame and embarrassment that someone close to them would do such
a thing will stop them from reporting. If the abuser is a child or grandchild, the older
person may be reluctant to report; they do not want their “loved” ones to get into
trouble (RAINN 2019). In addition, if the older person discloses the abuse, they
might not be believed due to assumed or actual deteriorating mental capacity and
old age. In residential care facility settings, the staff may be reluctant to report an
abuse if this involves a co-worker. This co-worker may have a good reputation and
the instinctual reaction might be disbelief, and a wish not to get involved (Teitelman
2006). From the administrator’s point of view, a disclosure of sexual abuse occur-
ring in their facility may be a threat to their reputation and along with a wish to
avoid a possible lawsuit; this may stop reports from being passed on.
6.7 Responses toSexual Abuse
Addressing elder sexual abuse requires a multi-dimensional approach. On an indi-
vidual level, professionals have a clear responsibility to take action on any suspicion
of sexual abuse. When sexual abuse is known to have happened, or is suspected to
have happened, the focus must be on immediate intervention.
A pilot study among staff in Norwegian nursing homes showed that staff were
not aware that sexual abuse might happen and the majority did not know how to
handle such cases if they occurred (Malmedal etal. 2016). The nursing staff asked
for more education on the topic, appropriate tools to assess possible abuse, and
guidelines for interventions. What was apparent in this study was that professionals
must face their own ageism regarding older persons and sexuality, since not viewing
older persons as sexual individuals may hinder their sensitivity to detecting sexual
abuse. Staff also need to be aware of the serious consequences of sexual abuse and
the need to respond as early and comprehensively as possible. A study by Teaster
and Roberto (2004a) shows that a strikingly low number of victims of sexual abuse
in nursing homes received physical or psychological treatment for the abuse, while
6 ‘If YouDo Not Believe That It Happens YouWon’t See It Either!’-Sexual Abuse…
80
a higher number of the perpetrators received psychiatric treatment. Yet both victims
and offender require help. Staff should also have knowledge concerning techniques
for the preservation of evidence of sexual abuse; wrongdoings at the early stage
could jeopardize the prosecution process against a perpetrator. Staff are mandated
by law and regulations to provide safe and high-quality care, and when this is not
the case, as when sexual abuse occur, the staff need to report and take appropriate
actions.
Responding to the sexual abuse of older people requires a multi-level response.
On the organizational level, the nursing home and home care management have a
duty to ensure that their staff are trained to handle elder sexual abuse cases, and that
they know when, how and where to report. Findings from a literature review show
that most nursing homes did not handle situations of sexual abuse in an adequate
way (Malmedal etal. 2015). Many nursing homes did not take proper action in
suspicions of sexual abuse or they delayed reporting it to authorities. There was also
a lack of documentation of abuse. Consequently, recommendations from Burgess
et al. (2000a) for facility responses to alleged sexual abuse are amongst others
immediate medical attention for victims, documenting detailed information, and
collaborating with law enforcement. Staff training is also imperative focusing on
signs and symptoms of suspected sexual abuse, patterns of abuse, victim impact,
perpetrator behaviors and appropriate responses (Burgess etal. 2000a).
However, recognition and detecting elder sexual abuse can be difcult. Health
professionals, whether in community, acute care or the residential care setting need
to be trained to implement screening tools for proper detection of elder sexual
abuse. Furthermore, healthcare professionals must also be clear about their inter-
vention responsibilities in line with safeguarding policy and legislation. A support-
ive working culture that encourages staff to speak up on behalf of the patients is
important to facilitate the disclosure of elder sexual abuse, thus whistleblowing
should be seen as a mechanism to improve care for older persons.
Resident to resident sexual aggression is an important issue. Teaster and Roberto
(2004a) underscore the necessity of adequate stafng and appropriate placement of
residents with behavioral problems. Vulnerable nursing home residents should be
protected by the facility and safeguarded to make sure they are not abused by other
residents.
On the societal level, elder abuse should be on the agenda for policy makers, and
the severity of such acts must be highlighted through public awareness. Furthermore,
there is a need for comprehensive policies and reporting systems as these represent
an important step in seriously addressing sexual abuse against older persons
(Malmedal et al. 2015). Some countries have independent advocacy services for
older people and mandatory reporting systems for elder abuse cases. This should be
implemented in all countries to ensure that fundamental safety for older persons are
secured. Other strategies on this level must target ageism in society and change the
negative stereotyping of older persons and upgrade the value of the work done by
caregivers in care for older persons.
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81
The WHO (2002:142) states that ‘prevention starts with awareness’ and empha-
sizes that health care providers should receive basic training on the detection of
elder abuse. Recognition of the problem of sexual abuse in older adults can be pro-
moted through education of the professionals and through public campaigns to raise
awareness in the society. In applying multiple methods of both prevention and inter-
vention, we can promote a safe environment of older people and ensure human
ourishing in older age.
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85© Springer Nature Switzerland AG 2020
A. Phelan (ed.), Advances in Elder Abuse Research, International Perspectives
on Aging 24, https://doi.org/10.1007/978-3-030-25093-5_7
Chapter 7
Self-Neglect inOlder Adults
MaryRoseDay
7.1 Introduction
Medical advancements have signicantly increased life expectancy, and people over
the age of 65 (older adults) are the fastest-growing population in the world (World
Health Organization 2015). Population aging has brought to the fore prevailing
under-discussed public health issues such as self-neglect. The National Centre on
Elder Abuse (NCEA) posits that Self-Neglect (SN) is ‘the behaviour of an elderly
person that threatens his/her own health and safety’ (Adminstration on Aging
2016). Self-neglect can vary in presentation and severity and was rst identied in
the 1950s. A variety of terms such as Diogenes syndrome (Reyes-Ortiz etal. 2014),
and domestic squalor (Snowdon etal. 2012) have been used to describe and dene
self-neglect (Gibbons etal. 2006; Lauder etal. 2009). A concept anlysis by Day
(2016) concluded that self-neglect can manifest both externally and internally and
dening attributes were environmental neglect and cumulative behaviors (service
refusal, isolation, poor social networks, reduced engagement, poor self-care, neglect
of health, hygiene, nutrition, and nances) that could be intentional or
non-intentional.
Self-neglect can have a signicant impact on older adults, family members and
communities (Day 2017a, b, Payne and Gainey 2005). Adverse outcomes associ-
ated with self-neglect include: caregiver neglect (Dong etal. 2013), emotional and
nancial abuse (Mardan etal. 2014) and signicantly increased mortality that can
be related to cancer or endocrine and nutritional deciencies (Baruth and Lapid
2017; Dong etal. 2009; Reyes-Ortiz etal. 2014; Schafer etal. 2017). In addition,
evidence supports that self-neglect results in increased use of hospital services
(Dong and Simon 2013a, 2015; Schafer etal. 2017), emergency department visits
M. R. Day (*)
School of Nursing and Midwifery, University College Cork, Cork, Ireland
e-mail: MR.Day@ucc.ie
86
(Dong et al. 2012a), hospice care (Dong and Simon 2013b) and nursing home
placement (Lachs etal. 2002).
Safeguarding and protection of adults who self-neglect is one of the most chal-
lenging and frustrating issues that health and social care professionals encounter
(Day etal. 2012; Braye etal. 2011). Determining adults’ mental capacity to make
an autonomous decision is a central aspect of self-neglect practice. Each self- neglect
situation is unique and uid and meaningful engagement, building relationships and
trust with clients to improve behavior is important (Day et al. 2017; Day and
McCarthy2017). Derogatory terms have been appropriated to describe situations of
self-neglect by younger people such as: ‘scrubber’, ‘ragger’, ‘bag lady’, ‘slimy
creep’, ‘tramp’, ‘lazinesss’ and ‘mental problems’ (May- Chahal and Antrobus
2012:1483). The concept of self-neglect is complex and historically Bozinovski
(2000) suggested the term ‘self-neglect was a misnomer.
7.2 Conceptualization ofSelf-Neglect
Self-neglect was rst identied in the 1950s and a variety of terms have been used
and reviewed in health and social care literature to describe and dene self-neglect
(Cooney and Hamid 1995; Shah 1995; Snowdon etal. 2007). The terms used include
senile breakdown syndrome (MacMillan and Shaw 1966), senile squalor syndrome
(Clark etal. 1975), squalor syndrome (Shah 1995) gross self-neglect (Cybulska and
Rucinski 1986), messy house syndrome (Barocka etal. 2004), senile recluse (Post
1982), domestic squalor (Snowdon etal. 2007, 2012) and Diogenes syndrome (DS)
(Clark et al. 1975; Reyes-Ortiz et al. 2014). The term Diogenes syndrome often
appears in the clinical literature in case reports as a diagnosis of self-neglect
(Cipriani etal. 2012; Esposito et al. 2003; Ngeh 2000; Pavlou and Lachs 2006).
Diogenes syndrome may be preceded by stressful events over the life course and is
characterized by:
…extreme self-neglect, domestic squalor, social withdrawal, apathy, a tendency to hoard
rubbish (syllogomania), and a lack of shame of living condition. (Pavlou and Lach
2006:836).
Hoarding disorder is a new addition to the Diagnostic and Statistical Manual of
Mental Disorders (DSM-5)–5th Edition (American Psychiatric Association 2013)
and no reference or recognition is given to self-neglect or animal hoarding. Hoarding
is characterized by persistent difculty in parting with possessions, which results in
the accumulation of belongings that congest and severely clutter and compromise
home living space. Animal hoarding is often associated with self-neglect.
A collaboration between nurse researchers in Scotland and the United States
dened self-neglect as:
The inability (intentional or non-intentional) to maintain socially and culturally accepted
standard of self-care with the potential for serious consequences to the health and wellbeing
of the self-neglecters and perhaps even to their community. (Gibbons etal. 2006:16).
M. R. Day
87
This denition captures the intentional and choice factors as well as the socio-
cultural inuence of the behavior and potential of the negative impact of self-neglect
for the individual, his or her family, and the community.
The Elder Justice Act (EJA 2010) in the United States dened self-neglect as:
An adult’s inability due to physical or mental impairment, or diminished capacity, to per-
form essential self-care tasks including (A) obtaining essential food, clothing, shelter, and
medical care; (B) obtaining goods and services necessary to maintain physical health, men-
tal health … (C) managing one’s own nancial affairs. (p.785)
This denition offers a comprehensive and concise conceptualization of self-
neglect. White (2014) suggests that adopting this denition would provide standard-
ization for research. Operational denitions, categorization and conceptualization
of self-neglect differ nationally and internationally (Braye etal. 2011; Daly and
Jogerst 2003). Neglect and self-neglect are frequently categorized and grouped with
elder abuse (National Centre Elder Abuse 2016). Self-neglect has been sidelined in
the context of abuse and neglect and designated as ‘the orphan’ by O’Brien (2014).
There is no one theory or explanatory model that can explain self-neglect (Paveza
etal. 2008). Self-care theory explains only some features of self-neglect (Lauder
2001, Pavlou and Lachs 2006). Gibbons (2009) determined that self-neglect theory
consists of two main concepts: self-care agency and deliberate action.
A number of conceptual models and frameworks have been used to describe and
understand self-neglect (Day and McCarthy 2016, Dyer etal. 2007a, b, Iris et al.
2010, Paveza etal. 2008). Dyer etal.’s (2007a, b) etiological model of elder self-
neglect, based on over 500 cases, described it as multiple decits in physical, social,
and medical domains as risk factors for elder self-neglect. Paveza etal.’s (2008) risk
vulnerability model focuses on internal and external risk factors as a framework for
the study of self-neglect and denes elements of risk and vulnerability. Iris etal.’s
(2010) conceptual elder self-neglect model captures the complex interplay between
physical/psychosocial and environmental inuences and the wide range of individ-
ual and population-level determinants and predisposing inuences. In summary,
there is no one all-encompassing explanatory model of elder self-neglect.
7.3 Epidemiology, Incidence andPrevalence ofSelf-Neglect
Self-neglect among older adults is the most commonly reported allegation to Adult
Protective Services (Dyer and Reyes-Ortiz 2017). There is a growing body of research
evidence on self-neglect, but a dearth of information remains on how to systemati-
cally estimate the prevalence and measurement of self-neglect (Abrams etal. 2018;
Day and McCarthy 2016; Dong 2017). According to the National Centre of Elder
Abuse (1998) incidence study in the United States, for every one case of self-neglect
reported to authorities, about ve more cases go unreported, a phenomenon they refer
to as the ‘iceberg effect’. To date, there is no data on incidence or prevalence of self-
neglect in adults presenting to acute hospital services (O’Connor 2017).
7 Self-Neglect inOlder Adults
88
Early estimates reported the incidence of Diogenes syndrome as 0.5 per 1000 of
the population in community dwelling adults aged 60 or over living at home (Berlyne
etal. 1975). Australia cited an incidence of 0.7 per 1000 of people age 65years and
older and living in moderate/severe squalor (Snowdon and Halliday 2009). A semi-
nal Irish survey (Hurley etal. 1997) concluded a prevalence rate of 3.8 per 10,000
for self-neglect in community dwelling adults. In Scotland, data from General
Practitioner (GP) caseloads suggests that self-neglect prevalence rates vary from
166 to 211 per 100,000 people (Lauder and Roxburgh 2012). Day etal.’s(2016)
retrospective review of student public health nurses’ (PHNs) community prole and
health need assessments (CPHNA) in Ireland suggested a prevalence rate for self-
neglect of 142 cases per 100,000 population. Self-neglect was seen in all ages but
prevalence was lower at 31 cases per 100, 000in younger people. Irish prevalence
data is, therefore, similar to data from GP caseloads in Scotland.
Data on self-neglect has relied on case reports from social service agencies and
a number of population based studies that have shown a range of prevalence esti-
mates. Dong et al. (2012b) assessed Personal and Environmental circumstance
using a 21 item observations tool (5 domains: hoarding, poor basic personal hygiene,
house in need of repair, unsanitary conditions and inadequate utilities). Prevalence
of self-neglect for men aged 65–74years was 9.5%; aged 75–84years was 9.2% and
for those age 85 or older it was 10.1%. The prevalence of personal and environmen-
tal hazards among women were 8.5% in the 65 to74 age group, 7.9% in 75–84 age
group and 7.5% in 85years and over age group. The prevalence of overall self-
neglect increased signicantly as health status lowered especially in men (Dong
etal. 2012b).
The prevalence of self-neglect can vary greatly across ethnic groupings in popu-
lations. A study on 5519 older adults from the Chicago Health and Aging Project
(CHAP) found a signicantly higher prevalence of self-neglect among African–
Americans (21.7%) and 5.3% among whites (Dong etal. 2012b, c). A cohort study
by Dong and Simon (2016) of 3159 community-dwelling Chinese older adults in
Chicago found that the overall prevalence of self-neglect was 29.11%, with 18.24%
being classied as mild and 10.87% as moderate to severe.
In South Korea, Lee and Kim’s (2014) study of 1023 older adults living alone
reported that 22.8% of older adults had some form of self-neglect. In the Republic
of Ireland (ROI), National Data on Safeguarding reported that 418 of concerns
received, 7% of the overall cases, related solely to alleged self-neglect, and most
related to people aged over 65years (Health Service Executive 2016). The identi-
cation of self-neglect can be highly subjective and reports support that self-neglect
is largely hidden and not reported. Self-neglect is a complex multifaceted entity, and
is linked to a range of etiologies (Burnett etal. 2014).
M. R. Day
89
7.4 Risk Factors forSelf-Neglect
A dearth of rigorous longitudinal studies have impacted on the clarication of previ-
ous cross sectional data of associated risk factors that may lead to self-neglect
(Dong 2017). Self-neglect was associated with a range of diseases include demen-
tia, depression, cardio-vascular disease, diabetes, and other psychiatric disorders
(Dyer etal. 2007a, b). Depression and cognitive impairment are major predictors of
self-neglect in community-dwelling adults (Abrams etal. 2002). A decline in execu-
tive functioning was associated with greater risk of reported and conrmed elder
self-neglect (Dong etal. 2010a). Reduced physical function, depression, executive
dysfunction, and drug and alcohol abuse are associated with self-neglect (Dong
etal. 2010b, c; Dyer etal. 2007a, b; Gibbons 2009; Pickens etal. 2013). Alcohol
abuse, low self-rated health, and pain were associated with higher depression in
people who self-neglect (Hansen etal. 2016). Self-neglect is signicantly associ-
ated with increased risk of self-reported suicidal ideation in a United States Chinese
population (Dong etal. 2017) and higher self-neglect scores were associated with
signicantly poorer quality of life in rural China (Zhao etal. 2017).
Self-neglect can affect adults across demographic strata and social classes
(Hurley etal. 1997; Day etal. 2016). The factors associated with self-neglect include
age, reduced social engagement and poor social support, (Dong etal. 2010c; Dyer
etal. 2007a, b; Ernst and Smith 2011), pre-frailty (Lee et al. 2016), poverty and
isolation (Spensley 2008), lack of access to health services (Choi etal. 2009), poor
coping (Gibbons 2009), medical neglect (Burnett etal. 2014), non-compliance with
medication (Turner etal. 2012), risk for harm (Tierney etal. 2004), and homeless-
ness (Snowdon 2011).
Etiologically, self-neglect in later life has been linked to traumatic personal expe-
riences (Band-Winterstein 2016; Band-Winterstein et al. 2012; Lien et al. 2016;
Day etal. 2013). Unique insights into life history and narratives of people who self-
neglect portrayed characteristics of suffering, loss, childhood abuse, uprootedness
and migration (Band-Winterstein 2016; Day etal. 2013) and traumatic life events in
early years (Lienetal. 2016; Monfort etal. 2017). Life history can inuence inten-
tion to self-neglect and understanding current behavior in context of antecedents
and life experiences of individuals who are self-neglecting as well as contextual and
environmental effects is important (Band-Winterstein 2016). An investigation of
farm animal welfare incidents observed serious health issues among farmers such as
alcohol addiction, depression, loss following death of a parent, and stress due to
increased paperwork (Kelly etal. 2011). High stress levels, economic vulnerability,
depression, mental health problems and suicide (Devitt etal. 2015) among farmers
may increase the risk for human self-neglect and impact on relationships between
7 Self-Neglect inOlder Adults
90
farmers and their animals (Devitt and Hanlon 2018). Self-neglect is not just a life-
style choice, antecedents and risks factors need to be explored and understood espe-
cially the past history of an adult who is self-neglecting reviewing their wishes and
feelings in relation to the risks. Typically, self-neglect cases focus on severe cases,
and threshold of what constitutes extreme self-neglect is subjective and views may
differ between professionals (Day etal. 2013).
7.5 Assessment andMeasurement ofSelf-Neglect
The absence of a specic self-neglect measurement instrument has impacted on
both research and practice. A range of assessment tools have been developed to
characterize and assess self-neglect objectively and include the Self-Neglect
Severity Scale (SSS), 26 items (Dyer etal. 2006), Self-Neglect Assessment Measure
(Day and McCarthy 2016), Abrams Geriatric Self-Neglect Scale (AGSS) (Abrams
etal. 2018) and the Elder Self-Neglect Assessment (ESNA) (Iris etal. 2014). A 10
item Environmental Cleanliness and Clutter Scale (ECCS) measures and observes
the severity of domestic squalor and hoarding (Halliday and Snowdon 2009).
The Self-Neglect Severity Scale (Dyer etal. 2006) includes observational and
self-report data and 3 domains of self-neglect as indicators: Personal hygiene
(example: dirty hair, clothing, unkempt nails and skin), impaired function (example:
decline in activities of daily living and cognition); and environmental neglect
(example: unclean house or yard and inability to manage material goods accumu-
lated over the years).
The Self-Neglect Assessment Measurement (SN-37) (Day and McCarthy 2016)
includes 37 items and 5 factors: environment (12 items), social networks (7 items),
emotional and behavioral liability (8 items), health avoidance (6 items) and self-
determinism (4 items). Each item is completed based on three-point scale ranging
from no evidence, yes, and don’t know. Principal components factor analysis sup-
ported the SN-37 SN-(factor loadings=0.4 or >), explaining 55.6% of the variance
and cronbach’s alpha (α) for four subscales ranged from 0.83 to 0.89 and one sub-
scale was 0.69. The SN-37 can be used not only to measure SN, but also to develop
interventions in practice.
The Geriatric Self-Neglect Scale (Abrams et al. 2018) has three subscales
Subject, Observer, and the Overall Impression and six domains (prescription medi-
cines, personal care, nutrition, environment/housing, nancial stewardship and
socialization). Environmental neglect is a central factor and foci in the measurement
of self-neglect (Day and McCarthy 2016; Abrams etal. 2018). At present no objec-
tive measure is used in the assessment of self-neglect in the Republic of Ireland. The
domains for assessment of self-neglect in the Health Service Executive policy
(2014) are personal appearance, functional assessment and medical needs, environ-
ment and nutrition. There is considerable variation in the continuum and severity of
self-neglect (range of behaviors and environmental conditions) and threshold to
which the word extreme self-neglect and squalor may be applied.
M. R. Day
91
7.6 Legislation andPolicy
There are variations in State laws, policies and services internationally on elder
abuse and self-neglect. State laws and processes differ across the United States;
some states embrace self-neglect under adult protective services and many include
self-neglect under denition of elder abuse (Teaster et al. 2006). Since 2014,
England has widened the remit of legislation and policy to include self-neglect
(Department of Health (DH) 2017), Care and Support Statutory Guidance (DH
2017). Scotland includes self-neglect within the code of practice (Scottish Executive
2014) that supports the implementation of the Adult Support and Protection
(Scotland) Act (2007). This differs in Australia where self-neglect and squalor are
not categorized as elder abuse as there is no third party involvement (McDermott
etal. 2009). In Australia, community professionals (health services, housing and
council staff) differentiated between environmental neglect (squalor) and behav-
iours that involve neglect of self-care and hoarding (McDermott 2008).
The Safeguarding Vulnerable Adults policy in Ireland (Health Service Executive
(HSE) 2014) denes a vulnerable person as an adult who may be restricted in capac-
ity to guard himself/herself against harm or exploitation or to report such harm or
exploitation (HSE 2014). Self-neglect is, therefore, excluded from the denition of
elder abuse in Ireland. The HSE (2014) policy includes processes whereby concerns
of extreme self-neglect can be referred to Safeguarding and Protection Teams. A
number of denitions for self-neglect are included in the safeguarding policy (HSE
2014:45) such as: Self-neglect in vulnerable adults is a spectrum of behaviors
dened as the failure to, (a) engage in self-care acts that adequately regulate inde-
pendent living or, (b) to take actions to prevent conditions or situations that adversely
affect the health and safety of oneself or others. The threshold for extreme self-
neglect is highly subjective (Day and McCarthy 2016; HSE 2014). Moreover,
Ireland lacks a legislative framework for safeguarding concerns (Donnelly etal.
2017) and current processes have been described as “ad hoc and reactionary”
(Donnelly and O’Brien 2018: 3).
7.7 Assessment
In the context of safeguarding, decision-making capacity is a central factor and can
affect an individual’s perceptions of risk and need for intervention. Executive func-
tion is maintained by the frontal lobe of the brain and is necessary for planning,
initiation, organization, self-awareness and execution of tasks which are critically
important for protection and safety and independent living. Executive dysfunction
inhibits appropriate decision making, problem solving and execution of decisions to
enable adults to live safely at home (Schillerstrom etal. 2009, Terracina etal. 2015).
Self-neglect and hoarding cases are challenging and complex public health issues
and place a signicant burden on services and agencies resources. Hoarding disorder
7 Self-Neglect inOlder Adults
92
and self-neglect are often hidden behind closed doors due to embarrassment, fear of
eviction and limited insight or appreciation of their impact on health, well- being or
environment and this will mitigate against people seeking help. A fall is often the
precursor to a referral by a neighbor or family member to primary healthcare staff,
community nursing, social worker or safeguarding team.
A risk assessment will need to be undertaken which gives consideration rstly to
observation of the person in their home living environment. A comprehensive per-
son–centred approach to clinical assessment needs to be undertaken that encom-
passes physical, psycho-social, behavioral and environmental factors once a concern
or suspicion of self-neglect is identied. The assessment needs to identify unique
needs of the older person, including their life history and story to understand under-
lying causes, meaning and reasoning of the behaviors and draw on knowledge from
a wide range of sources and include family if available. Family can provide impor-
tant information and context and can be a helping resource in developing care plans.
However, they do not have decision-making authority (in Ireland at least) if the
person has capacity or if there is no legal sanction for decision making (Enduring
Power of Attorney, Wardship (until 2015 Act is implemented). The assessments will
be able to determine and evaluate the need for assistance, prioritize immediate
needs and safety issues, dene potential or actual risk and concerns, assess available
resource, and consequences of self-neglecting behaviors on health, safety and well-
being. The risk assessment needs to identify potential re hazards, pest infestation,
and impact of hoarding on individual, family members and community. Risk has
two variables: likelihood that something will happen and seriousness (outcome).
Professional judgment applies sound professional knowledge and understanding to
each decisions made.
A person-centred approach to care respects and promotes individual freedom of
choice, dignity, independence and desire for personal autonomy and self-
determination despite increasing dependency (Beauchamp and Childress 2012).
The Assisted Decision Making Capacity Act (2015) takes a functional approach to
capacity; there is a presumption that the person has capacity unless proven other-
wise. The focus is on supporting people to make decisions and respecting individu-
al’s choice and recognizing the right to make unwise decisions. Capacity is decision
specic, issue specic and time specic and should not be viewed as an attribute for
all decisions made by the individual (Braye etal. 2017a). (see Phelan and Rickard
Clarke, Chap. 3, in this volume).
Self-neglect is a complex area of practice and practitioners can feel isolated and
helpless when balancing of autonomy, protection and risk (Mulcahy etal. 2017,
Braye etal. 2017a). The most challenging elements of self-neglect practice was iden-
tied as ‘ne balance’ and related to the clients’ capacity and/or refusal/reluctance to
engage with services (Braye etal. 2014, Mulcahy etal. 2017). An ethical decision-
making tool can be used to provide a stepwise approach to reect on the ethical
dimensions (values, rules and principles) and evaluate the merits and demerits of
possible courses of action (Campbell and McCarthy 2017; Day and McCarthy 2017).
Through a conversational approach, engaging with client, building trust and a
therapeutic relationship, health and social care professionals can foster relationships
M. R. Day
93
with the older person. This encompasses negotiating and working with self-
neglecting adults, assisting and helping them to think through their situation and
concerns and identifying what is working well or not working. Forming an overall
goal with the person is central to person centred care principles. Seeking family
members’ perceptions or insight into situation is important but they do not have
decision-making authority. Accordingly, a health or social care practitioner makes a
professional judgement based on the evidence and analysis and uses both subjective
and objective knowledge. Care plans also need to ensure that interventions are pro-
portionate to the signicance and urgency of the situation and the behaviours.
In the event that the person is refusing services choosing to walk away, and ‘non-
interference’ can have adverse outcomes in protection of person from harm.
Maintaining contact, building a relationship of trust over time can lead to opportuni-
ties for the person to accept interventions and supports. Social support is critical to
enabling and supporting people to remain in the community. In as far as possible,
the assessment process needs to be person-centred and the person should be funda-
mental in co-developing a Safeguarding Plan to reduce or eliminate the identied
risks (Day etal. 2015; Day and McCarthy 2017). Assessment is a process and ongo-
ing review and evaluation of case is important. The HSE (2014) policy on self-
neglect supports a multi-disciplinary and/or multi-agency involvement that supports
shared risk management and shared decision-making. Practitioners need to be
knowledgeable of the legislation and policy that can be relevant when responding to
self-neglect in their jurisdiction. Effective self-neglect practice is founded on legal
knowledge, ethical knowledge, emotional literacy, relationship-centered care,
knowledge collated from a wide range of sources, organizational knowledge and
decision-making (Braye etal. 2017b; Day and McCarthy 2017). Responding and
intervening to improve clinical outcomes for people who self-neglect is very impor-
tant (Lee etal. 2018).
7.8 Conclusion
Self-neglect is a growing serious and complex public health issue and excellent
safeguarding practice must be at the core of adult protection services. There is no
one overarching theory of self-neglect and absence of a universal denition and
subjectivity in assessment has been problematic for research and practice. Mental
health issues are associated with and a signicant risk for self-neglect. Self-neglect
is a complex and multifaceted issue and each case is unique and requires individual-
ized person-centred responses and interventions. Knowledge, legal literacy and
skilled application of legislation and policy are essential. Relationship based prac-
tice making safeguarding personal and understanding the person’s life history, seek-
ing positive engagement and exible supportive responses can improve outcomes.
Sometimes people who self-neglect may choose to live in situations that are consid-
ered as sustaining harmful environments which negatively impact their well- being.
Professional judgment and ethical, person centred decision-making is central to
7 Self-Neglect inOlder Adults
94
safeguarding process, while multi-disciplinary and multi-agency responses are cen-
tral as are supervision and support. Consequently, reective therapeutic engagement
is essential to safeguarding adults who self-neglect and safeguarding is ‘everybody’s
business’.
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7 Self-Neglect inOlder Adults
101© Springer Nature Switzerland AG 2020
A. Phelan (ed.), Advances in Elder Abuse Research, International Perspectives
on Aging 24, https://doi.org/10.1007/978-3-030-25093-5_8
Chapter 8
Financial Abuse ofOlder People
AmandaPhelan
8.1 Introduction
Elder abuse is an issue which permeates all societies. As global populations increase,
safeguarding older people is a fundamental goal of societies. Within the manifesta-
tions of elder abuse, nancial abuse (FA) has been shown to be the rst or second
more prevalent form of abuse (Naughton etal. 2010; Acierno etal. 2010; Yon etal.
2017). Yet, it is generally under reported, under prosecuted and under researched
(Jackson and Hafemeister 2011). Consequently, in a White House conference on
ageing in the United States, Pillemer etal. (2015) identied FA as a key policy and
research area for action and it has been recognized as an important public health
challenge (Payne and Strasser 2012; Yon etal. 2017).
This chapter examines the issue of FA of older people. Older people represent a
disproportionate number of people who are nancially abused as they may have
accrued assets during their life and have ‘nest eggs’. Financial abuse is the only
form of abuse that can occur remote from the older person. Challenges in identify-
ing FA can include a complex case presentation where there can be blurred lines
regarding expenditure, capacity and consent as well as issues related to family
expectations and cultural norms (Jackson and Hafemeister 2011). It is estimated
that $2.9 billion was taken from older people in the United States in 2010 (MetLife
Mature Market Institute etal. 2011) while in 2007/2008, it is estimated that approxi-
mately Aus$ 1.8–5.8 billion was taken from older Australians (Jackson 2009).
A. Phelan (*)
National Centre for the Protection of Older People, School of Nursing,
Midwifery & Health Systems, University College Dublin, Beleld, Dublin, Ireland
e-mail: Amanda.phelan@ucd.ie
102
8.2 Dening Financial Abuse
Globally, there are many different denitions of FA of older people (Fealy etal.
2012) and the diversity, changing modes of perpetration and case complexity can
make universal understandings challenging (Centre on Policy on Ageing 2010). In
addition, poor reporting, nancial mismanagement, issues related to consensual
intergenerational nancial support, culture as well as blurred lines on costs in nurs-
ing homes exacerbate a lack of precision in common denitions (Crosby etal. 2008;
Carter-Anand etal. 2014; Phelan and McCarthy 2016; Lloyd-Sherlock etal. 2018).
Despite the lack of a common consensus in denition, Vancity (2014) suggest three
general ways FA can be perpetrated; it can involve monetary abuse, legal abuse or
property abuse perpetrated on an older person. This can also encompass a failure to
access benets and can involve mismanagement of funds or opportunistic abuse of
nances by another person (Crosby etal. 2008). The World Health Organization
(WHO 2002a: 128) identies nancial elder abuse as ‘the illegal or improper exploi-
tation or use of funds or other resources of the older person.’ However, this deni-
tion is considered very wide-ranging and not specic enough to provide a
comprehensive understanding (Darzins etal. 2009). In the Republic of Ireland and
Northern Ireland, the denition of FA is more detailed and there are commonalities
in terms of what constitutes this type of abuse:
Actual or attempted theft, fraud or burglary. It is the misappropriation or misuse of money,
property, benets, material goods or other asset transactions which the person did not or
could not consent to, or which were invalidated by intimidation, coercion or deception. This
may include exploitation, embezzlement, withholding pension or benets or pressure
exerted around wills, property or inheritance. (DHSSPS and DoJ 2015: 13)
Financial or material abuse includes theft, fraud, exploitation, pressure in connection with
wills, property, inheritance or nancial transactions, or the misuse or misappropriation of
property, possessions or benets. (Health Service Executive 2014: 9)
Denitions are also blurred by issues of perceived consent of the older person in
giving money or assets to another person, yet this could be because of undue inu-
ence or involve some form of deceit. Moreover, there can be multiple forms of FA
being perpetrated on the older person, for example, theft, fraud, orpressure to sign
wills (Jackson and Hafemeister 2011; Phelan etal. 2014). Dessin (2000) proposes
four manifestations of FA.Firstly, it can constitute a criminal act, such as theft or
robbery and is identied in the 2010 Elder Justice Act in the United States as an act
of violence (Price etal. 2011). Secondly, it can be perpetrated through fraud and
scams. Thirdly, Dessin (2000) suggests a special category for the nature of the rela-
tionship with the older person where the trusted person intentionally misuses the
assets of the older person. The nal category encompasses the negligent handling of
the older person’s assets, which may not be intentional.
Payne and Strasser (2012) examined FA in nursing homes, and suggest cases of
embezzlement and fraud can constitute occupational crimes (for example, perpetrators
who are staff in nursing homes). Although FA may often not meet standards of criminal
A. Phelan
103
law (Smith 1999), Payne and Strasser (2012) advocate that legal responses need to be
within the criminal justice system, rather than within the domain of civil justice.
In dening FA of older people, the issue of ‘who’ is the perpetrator is also rele-
vant. For example, in the WHO (2002b) denition of elder abuse, it is stated that
abuse occurs within a relationship of trust, clearly dening abuse by the type of
perpetrator rather than the act of abuse. Bonnie and Wallace (2003), for example,
state that FA by strangers is not a form of elder abuse while Jackson (2015) and
Burnes etal. (2017) take a wider interpretation, suggesting personal abuse is consti-
tuted by people known to the older person, while commercial abuse represents
opportunistic nancial exploitation (i.e. scams and mass marketing fraud) (MMF)
(Jackson 2015). A further consideration in dening FA is whether it is pure or
hybrid. Jackson and Hafemeister (2011) propose that pure FA is where nancial
exploitation is the only maltreatment experienced by the older person, while hybrid
abuse involves a clustering with physical abuse and/or neglect. The co-existence of
abuse typologies in elder maltreatment is not uncommon (Naughton etal. 2010).
8.3 Prevalence
As there are varied denitions of FA, it is difcult to identify a true prevalence. This
is compounded by indistinct boundaries related to culture and undue inuence as
well as the variety of methodological approaches used to study the topic. In addi-
tion, different studies have used varying age limits with some using 60years or
older while others use 65years and older. Despite this, general prevalence studies of
elder abuse have often identied nancial abuse as either the highest or second
highest form of abuse experienced by older people. However, these gures are likely
to be underestimates of the true prevalence (Deane 2018).
Studies that have recorded the incidence and prevalence of FA in older people
indicate that it predominantly occurs in the home environment (Centre for Policy on
Ageing 2010; Wainer etal. 2010). Within this setting, the general prevalence of FA
is unclear (Van Bavel etal. 2010) and commentators vary from a general reporting
ratio for older people of 1:5 (Hannigan etal. 1998) to 1:25 (Wasik 2000) to 1:100
(Malks et al. 2003). The Social Care Institute for Excellence (SCIE 2011a, b)
observe that older people who come to the attention of safeguarding professionals
in health and social care, may not always report FA as a nancial crime to police
services. In addition, SCIE (2011a, b) notes that those with a high degree of inde-
pendence may not be located within safeguarding services but may instead be in
contact with other organizations and may also not be referred to the police service.
An incidence study in the US (NCEA etal. 1998) found that a signicant number
of conrmed elder abuse cases (30.2%) involvedFA.However, prevalence rates can
vary widely, even within countries as demonstrated in Table8.1.
A wide prevalence variation was observed in a NewYork study (Lifespan of
Greater Rochester Inc. etal. 2011) where the older person’s self-reports of FA were
compared with those reported by formal response agencies. In this study, a FA ratio
8 Financial Abuse ofOlder People
104
of only 0.96 per 1000 was detected by such formal services as opposed to 42.1 per
1000 as reported by the older respondents. This suggests a major under-reporting of
FA to ofcial agencies, such as legal, police, health and social care services, which
may be due to issues of embarrassment, family ties, not recognizing FA as an abuse
perpetration as well as a lack of services being able to detect the abuse. Another
study demonstrated a higher prevalence of FA being identied by proxy accounts as
opposed to older people themselves (13% as opposed to 11%) which may prove
important in terms of improving reporting sources (Acierno etal. 2009).
8.4 Prevalence inCare Settings
There are scant studies which looked at FA of older adults’ formal care environ-
ments. One study demonstrates an 8.9% prevalence of nancial abuse in hospital
based older people (Cohen etal. 2007). Nursing home staff may perpetrate multiple
incidences of FA over a period of time and on multiple residents (Payne and Strasser
2012). This may be facilitated by the relatively easy access to older people who have
Table 8.1 Prevalence of FA in selected published studies
Country
Prevalence gure (12month period)
% (unless otherwise stated)
Community based sample (unless
otherwise stated) Author and year
Finland 8.5 Kivela etal. (1992)
United Kingdom 0.7 O’Keeffe etal. (2007)
Ireland 1.3 Naughton etal. (2010)
United States 3.5 Laumann etal. (2008)
United States 5.2
Lifetime experience of FA by
strangers was reported as 6.5%
Acierno etal. (2009)
Israel 6.4 Lowenstein etal. (2009)
World Health Organisation
European Union
3.8 Soares etal. (2010)
Sweden 1.8 Soares etal. (2010)
Italy 2.7 Soares etal. (2010)
Lituania 2.8 Soares etal. (2010)
Austria 4.7 Soares etal. (2010)
South Carolina 6.6 Amstader etal. (2011)
South Africa 30 Bigala and Ayiga (2014)
Macedonia 12 Peshevska etal. (2014)
Norway 0.5 Sandmoe etal. (2017)
Global estimate (based on 52
studies in 24 countries)
6.8 Yon etal. (2017)
Canada 2.5 McDonald (2018)
A. Phelan
105
cognitive and/or functional health challenges and the high degree of one to one
interaction. For example, an early study by Harris and Benson (1998) suggests that
one fth of older people in nursing homes may be subject to FA on an annual basis.
This compares to an Irish study of interactions and conict in nursing homes
(Drennan etal. 2012) where staff respondents, comprised of nurses or healthcare
assistants, reported observing a colleague perpetrating FA once (0.9%) and between
2 and 10 times (0.3%) in the previous 12months. Drennan etal.’s (2012) study also
demonstrated low gures in the respondents’ own self-reported perpetration of FA
(0.3% for one episode of FA and 0.3% for between 2 and 12 perpetrations of FA) in
the previous 12months. A much higher gure of the prevalence of nancial abuse
in residential care was suggested by Yon et al. (2018), who examined data from
three studies from three different countries. Yon etal. (2018) estimated a nancial
abuse pooled prevalence of 13.8% in nursing homes. Prevalence of FA in residential
care for older people requires additional research, particularly in relation to issues
related to residential care management of the person’s money and also, how nances
and property are administered by relatives when an person is in residential care.
8.5 Theories ofFinancial Abuse
Kemp and Mosqueda (2005) reviewed relevant literature and developed an eight
item assessment for FA.These items, together with two FA conceptual frameworks
in the literature (Wilber and Reynolds 1996; Rabiner etal. 2005) broadly identify
three issues in the context of FA– (a) the vulnerability of the older person, (b) the
quality of the older person-perpetrator relationship and (c) how this relationship is
rendered exploitative. These three areas are discussed in detail below.
8.5.1 Vulnerability oftheOlder Person: Gender andFA
Some prevalence studies have identied that women are more vulnerable to nan-
cial abuse (NCEA etal. 1998; MetLife Mature Market Institute etal. 2011; Darzins
etal. 2009). This may be inuenced by the fact that women live longer and are
proportionately larger in numbers in the general population of older people.
Genderized roles may impact on the experience of FA.For example, due to tradi-
tional roles within marriage, older women may be inexperienced in managing
nances, particularly after a spousal death, and may depend on others to assist with
nancial management which increases risk (British Columbia Healthlink BC 2014).
Women are also considered to be more trusting and may believe their traditional
genderisedrole as mother or caregiver translates to children or others having the
entitlement to assets or nances. Conversely, older men may seek a replacement for
a caregiving role and be vulnerable prey to female perpetrators. In particular, the
‘Sweetheart Scam’, can target lonely older men, although this form of FA may also
8 Financial Abuse ofOlder People
106
be perpetrated on older females (MetLife Mature Market Institute etal. 2011). Both
sexes are considered to be particularly vulnerable to scams involving befriending, as
social networks may decrease due to family having other commitments, geographic
distance, immobility, cognitive function and the death of family members and
friends, thus the older person’s social capital (Rabiner etal. 2005) is diminished.
8.5.2 Ageing andFA
Financial abuse may occur at any age but common age related factors can heighten
risk (Smith 1999; Burnes etal. 2017). For example, research has pointed to deterio-
ration in the anterior insula in the brain which controls perception (Castle et al.
2012). The increased vulnerability to fraud is attributed to a reduced ‘gut’ response
to cues of untrustworthy characters. Thus, the ageing brain contributes to impover-
ished acuity and enhances vulnerability to FA.
Age is a risk factor for functional and cognitive decline (Millān-Calenti etal.
2011; Prince etal. 2013) and such impairments have been linked to a risk of older
people experiencing FA (Samsi etal. 2014; Choi et al. 1999; Wainer etal. 2010;
Wood and Litchenberg 2017). Older people who experience cognitive or functional
challenges may rely on others, particularly family members, for nancial manage-
ment assistance and such dependency can promote an unequal power dynamic
within relationships, potentializing vulnerability. When health status declines, access
to banking or engaging in daily activities involving money, such as collecting pen-
sions, shopping, paying bills, could be rendered difcult and a third party, usually a
relative, may be given access to the older person’s nances. However, within such
informal arrangements, there can be a lack of independent scrutiny regarding nan-
cial management. In relation to permitting a nominated individual to manage nan-
cial affairs, Setterlund etal. (2007) advocates using the routine activities theory to
examine how the role of ‘asset managers’ is practiced (someone who has control
over decisions and management of the older person’s assets). This role may be
undertaken in a responsible way, where asset managers keep judicious records and
demonstrate transparency and accountability in being a ‘capable guardian’. However,
poor asset managers may engage in risky practices by blurring expenditure ratio-
nales, merging bank accounts and being accountable only to themselves (Setterlund
etal. 2007). A careful review and monitoring of such activities can help to regulate
and monitor for unacceptable nancial activities, particularly within families.
As managing nances can be a complex task involving higher order executive
function, older people with cognitive impairments may have a reduced ability to
both protect themselves and whistle blow in the event of FA (Davies etal. 2011;
Samsi etal. 2014). Financial capacity encompasses a range of skills from the basic
counting of money to more complex activities such as bill paying and managing
accounts. Marson etal. (2000) argues that an appraisal of nancial capacity is often
overlooked in health assessment, although this is a major element of individual
autonomy and is fundamental to many legal and ethical issues pertaining to the
A. Phelan
107
older person with cognitive decline. Yet, nancial capacity encompasses many
domains which Martin etal. (2008) identies as (a) basic monetary skills, nancial
conceptual knowledge, (c) cash transactions, (d) chequebook management (e) bank
statement management (f) nancial judgment, (g) bill payment (h) knowledge of
personal assets/estate arrangements and (i) overall decision making. People with
mild cognitive impairment (MCI) can live independently; however, higher order
abstract thinking is amongst the rst abilities to diminish and may go unnoticed for
a period of time. For instance, one study indicated that nancial capacity is dimin-
ished in older people with mild cognitive impairment in the year before diagnosis of
Alzheimer’s disease (Triebel etal. 2009). Consequently, the use of screening for
nancial capacity of adults at risk is useful in the context of a multi dimensional
assessment, such as in the Semi-Structured Clinical Interview for Financial Capacity
(SCIFC) (Marson etal. 2009), Martin etal.’s (2008) domains of assessment or the
informal assessment to probe for potential nancial impairment or vulnerability
(Widera etal. 2011). Such screens examine executive functioning related to nan-
cial capacity and can aid health practitioners’ assessment of this important aspect of
autonomy. If there is evidence of impairment in nancial capacity, practical steps
can be taken to promote nancial protection. One of the most vital of these steps in
FA is to have expert assessment whether the person has the ability to understand the
consequences of the transaction.
8.5.3 Culture, Race andElder Abuse
Some studies have examined FA in relation to racial and cultural background. Culture
has an impact on values and beliefs and therefore inevitably on what behaviors are
accepted, and those which are not. For example, a collectivist approach (generally
seen in Eastern countries as opposed to an individualist approach generally seen in
Westernized countries) could justify the use of an older person’s nances and assets
for the greater good of the family/community. Moreover, in South Africa, there is a
moral pressure (by both family and state) to share pensions with family (Lloyd-
Sherlock etal. 2018). Wainer etal. (2011) also point out that women within many
Eastern countries experience economic dependency on men and may be expected to
hand over any income to their husbands or other male gures when their husbands
die, which may be interpreted as FA in Western culture. This can be underpinned by
historic inuences; for example, witchcraft laws from 1925 still exist in Kenya and
have been used to justify both physical violence and the acquisition of nances and
land of older people (Aboderin and Hatendi 2013). Equally, the English custom of
primogeniture, where the rst-born male child had a right to inheritance may also
have legacy issues as the perception of family entitlement to the assets of the older
person is considered an overwhelming contributing factor to nancial abuse.
Acknowledging this, it is also important to understand that such homogeneous val-
ues should not be taken for granted within cultures. The evidence of culture as a risk for
FA is mixed, with most studies occurring in the United States. Acierno etal. (2010) did
8 Financial Abuse ofOlder People
108
not nd any statistical signicance in rates of FA related to race, however, immigrant
groups, such as Koreans and black older people have demonstrated a higher prevalence
in an earlier study (Hafemeister 2003). Laumann etal. (2008) reported that African
Americans were more likely to report FA than Caucasians, while Latinos were least
likely to report FA.In a study based in Pennsylvania, Beach etal. (2010) found that the
prevalence of FA in older African Americans was three times higher than non-African
Americans (23% as opposed to 8.4%) and the risk for FA in the previous 6months was
estimated as eight times higher for African Americans than non-African Americans.
However, separate studies identied Caucasians as being at highest risk of FA (NCEA
etal. 1998; Choi etal. 1999).
An Australian study (Wainer etal. 2011), found that culture, race and language
prociency impact on money management and awareness of FA.For example, older
people who described themselves as being from a Greek, English or Italian origin,
regularly used wills and power of attorney, while this was not a common practice for
older people from Vietnamese origin. In addition, Greeks and Italians were more
likely to seek nancial advice from legal sources, while non-English speaking par-
ticipants used services such as banks for support. Essentially, Wainer etal. (2010)
argue that understanding the fundamental values in relation to culture, race, family
and nances underpins the responses to FA and this provides important pointers for
targeted service intervention and risk analysis. Certainly, the way FA is understood
is implicitly intertwined with cultural values and beliefs and this has had an inevi-
table impact on reporting, detection and intervention.
8.6 Quality oftheRelationship
The quality of the relationship between the older person and the perpetrator is
important to consider, taking in to account issues of culture, lifelong interactions
and individual perspectives. For example, family relationships may have improved
in recent times or deteriorated or relatives may be more or less involved in older
person’s life at particular times. Relationships may also be inuenced by the perpe-
trator’s nancial dependence on the older person (MetLife Mature Market Institute
etal. 2011). This may be a particular issue if the perpetrator is unemployed, has a
mental health issue, gambling or substance abuse dependency (Rabiner etal. 2005).
The older person may feel powerless to discontinue this negative relationship due to
fear, kinship bonds, a justication of the FA due to his/her dependency on the per-
petrator, or a threat of being abandoned or being admitted to residential care. They
may also feel powerless to discontinue this negative relationship due to fear, kinship
bonds, a justication of the FA due to his/her dependency on the perpetrator.
Financial abuse may be committed by anyone but a trusted family member is often
the most common perpetrator (Naughton etal. 2010). Within family relationships,
studies demonstrate that the most common single perpetrator of FA is the older
person’s child (Laumann etal. 2008). As indicated previously, a common percep-
tion by children is an entitlement to the older person’s assets, due to inheritance
A. Phelan
109
rights, kinship ties or that the older person can simply afford to lose/give away the
money or property (O’Brien etal. 2011; Conrad etal. 2011; Phelan 2013). Thus, the
older person’s assets may be considered to ‘belong’ to the child/relative and any
awareness of actual FA by the perpetrator may be minimized or rendered invisible.
With regard to scams, the relationship is new and the older person is lured via the
promise of some desirable advantage. This may be money, a gift, continued com-
munication but these are either not received or when received are of little relative
value compared to the nancial transaction. Often, scams are constructed in such a
way that there is hidden ‘small print’, ‘too good to miss’ advantages, and may also
involve false copies of real institution documentation/websites. It is the believability
and apparent genuineness of the scam agents that underpins the older person’s pro-
pensity to part with money or other assets. A recent review by Burnes etal. (2017)
suggests that 1in 18 cognitively intact older people living in the community may be
vulnerable to fraud and scams. After being lured in, it can be impossible to recover
such nancial outputs.
8.7 How theRelationship Is Rendered Exploitative
In many cases, FA is the result of a relationship gone wrong or where trust is betrayed
(Wilber and Reynolds 1996; SCIE 2011a, b; Phelan etal. 2018). FA may occur over
a gradual period of time, be recurrent or isolated and is generally shrouded in
secrecy and deceit, and can be mostly associated with family FA (Mansell etal.
2009). Kemp and Mosqueda (2005) suggest that FA can involve the lack of business
ethic, as there may be no written agreement, no ability to reverse a decision, a lack
of full disclosure and a lack of validation of nancial capacity to consent. It can be
very difcult to distinguish, particularly as there may be no visible signs of its per-
petration (Choi etal. 1999). Issues such as the perpetrator’s ‘intent’ and the blurring
of appropriate and exploitative use of nances may also complicate the discovery of
FA (Choi etal. 1999). Furthermore, the perpetrator may have believed that he/she
was justied in their actions or such actions may progress from supportive to abu-
sive (Smith 1999). The perpetrator may rationalize the expenditure or removal of
funds, which may, on the surface have the adult at risk’s assent, but deeper examina-
tion can reveal a lack of consideration of consequences of transactions. Moreover,
Conrad etal. (2011) and King etal. (2011) suggest that legislation which correlates
nursing home payments with an older person’s assets may also be used to justify the
‘transfer’ of monies, in order to escape payment.
Even when the older person is aware of the occurrence of FA, he/she may not
disclose itand this may only be discovered when the person engages with safeguard-
ing services, dies or is left penniless. The reasons for non-disclosure vary. The older
person may have an irrational trust (Tueth 2000) in the perpetrator and feel helpless
to refuse any demands (Rabiner etal. 2005) or be intimidated to agree to FA acts
(Kemp and Mosqueda 2005). Non-reporting may also be due to embarrassment,
particularly as many perpetrators are family members or considered ‘trustworthy’
8 Financial Abuse ofOlder People
110
people (Conrad etal. 2010). In addition, a fear of losing independence, not being
believed and both physical and cognitive challenges may prevent the reporting of the
abuse (Rabiner etal. 2005). Conversely, the older person may think that the way to
sustain the relationship is to endow the perpetrator with gifts, while the perpetrator
may have signaled an expectation of such gifts. This context represents an exploit-
ative emotional relationship resulting in FA.Furthermore, if the older person experi-
ences poor family support and limited social contact, this can impact on the potential
to detect FA and also reduce access to helping mechanisms (Naughton etal. 2010),
although Acierno etal. (2009) demonstrated that older people who use social ser-
vices were more at risk of FA, despite the increased potential for detection.
8.8 Consequences ofFinancial Abuse
There are signicant consequences for older people who have been nancially
abused. Financial insecurity has a negative impact on health status (Bisgaier and
Rhodes 2011; Burnett etal. 2016) and can lead to depression, stress, a compromised
independence, social isolation and the loss of human rights and dignity (MetLife
Mature Market Institute etal. 2011). In addition, unlike other cohorts of the popula-
tion, older people do not have the same capacity to generate substitute incomes. For
example, employment may be more difcult or even impossible to secure and older
people have limited methods of generating alternative funding sources (Nerenberg
1999; Smith 1999). The older person may have to turn to other family members for
support, which can increase stress within the family. Furthermore, there may be
other related effects on society. For instance, FA of an older person may create an
increased nancial dependency on government welfare systems and social services
(Setterlund 2001; SCIE 2011a, b) while abuse itself has been linked to higher rates
of hospitalizations and care services (Dong and Simon 2013).
8.9 Responding toFinancial Abuse
Responding to FA of older people is a multifaceted challenge which demands an
ecological approach (Bronfenbrenner 1979) encompassing micro, meso, exo and
macro levels, (O’Donnell etal. 2015). Micro levels focus on the relationships within
the immediate environment of the person; the meso level represents the interactions
between the micro-level systems such as social networks; the exo level refers to
interventions which impact the adult at risk but do not directly involve them, such
as the legal system, the economic system while the macro system relates to the
broader cultural domain of the over arching beliefs and values of a society (see
O’Donnell and Phelan in this book). For example, on a macro-level, a major aspect
of addressing FA is to change perceptions of older people in society.
A. Phelan
111
Ageiststereotypescontribute to constructing older people as being unable to man-
age their own affairs, having lesser needs and rights than ‘normal’ society and hav-
ing lesser value in society. Even, in the event of reduced nancial capacity, societal
perspectives need to promote a discourse which clearly identies that nances are
not transferred to another person, but are managed with the best interests of the
adult at risk (who always retains ownership). Changing attitudes and culture repre-
sent a major goal in the prevention of nancial abuse. Four major areas for protect-
ing from nancial abuse are safeguarding legislation, safeguarding in nancial
institutions, specialist multi-disciplinary teams and money management programs.
Other responses are covered in a separate chapter in this book based on empowering
older people to protect themselves from nancial abuse (see O’Donnell chapter in
this book).
8.10 Detecting Financial Abuse, Legislation, Policy
andPractice
8.10.1 Detecting Financial Abuse
Detection is complicated by a lack of knowledge and specic FA training of staff
(health and social care, legal personnel, banking staff) as targeted questions may not
be asked and warning signs not recognized (Rabiner etal. 2005). In particular, it has
been shown that older people are considered ‘low risk’ targets for FA, due to poor
reporting patterns. There is also a reduced likelihood of reporting as the older per-
son may fear being perceived as loosing cognitive function and even when the crime
is reported, there may be problems with memory pertaining to the precise details of
the incident(s) (FBI 2013). Consequently, early and adequate detection of FA is
fundamental to addressing the issue.
Due to the covert nature of FA, enabling detection is central to intervention.
This involves a number of strategies. The process of screening is considered a
fundamental, universal approach as an older person may not be aware of nancial
abuse and direct questions have the advantage of revealing possible dubious nan-
cial practices (Reeves and Wysong 2010). Clinicians have a dual role in asking
about changes in nance and any atypical expenditures. Moreover, clinicians may
be asked to give expert witness regarding issues of mental capacity or vulnerabil-
ity of the adult at risk to coercion. To date there is a dearth of screening tools
specically for nancial abuse. The only knownvalidated nancial abuse screen-
ing tool in the literature related to vulnerable adults is the Older Adult Financial
Exploitation Measure (OAFEM) (Conrad etal. 2010), which is comprised of 25
questions and has been shown to heighten a suspicion of nancial abuse (Phelan
etal. 2014). Essentially, any screening for nancial abuse should be incorporated
into the general assessment and interaction with the adult at risk to normalize the
process and reduce anxiety (Reeves and Wysong 2010).
8 Financial Abuse ofOlder People
112
8.10.2 Legislation
Legislation for older people who experience decision-making capacity challenges
demands a focus on functional capacity and the preservation of authentic consent
and autonomy. There are various legal protective interventions which can assist with
nancial management such as power of attorney, guardianship or decision making
representative. However, the regulation of the guardian’s activities is fundamental to
protecting nances and maintaining good practice (Setterlund etal. 2007). Consent
of an older person to sign over ownership of property may, on the surface appear to
be a simple activity, but it is necessary to examine the consequences of such an
action and who benets from this. Other related principles are those of undue inu-
ence and unconscionability. Undue inuence may be dened as inappropriate or
excessive manipulation of the older person, and is a major strategy used to gain
access to the assets although it can be challenging to identify cases where psycho-
logical pressure has been applied to sign apparently legitimate documents (Wilber
and Reynolds 1996; Gibson and Honn Qualls 2012). Thus, assets are transferred
during a period of vulnerability. Closely related to the principle of undue inuence
is the principle unconscionability. This involves an action that is detrimental to the
older person due to an imbalance in bargaining power. Thus, unconscionable acts
can include many aspects of FA, such as signing over property, funds and assets,
particularly in the context of decision making capacity impairment.
8.10.3 Financial Agencies
Financial agencies are an important early intervention mechanism as they may be
the rst to detect irregularities in nances and are in a unique position to assist in
protecting customers (BITS Fraud Reduction Steering Committee 2006). In address-
ing FA, research has increasingly emphasised the role of nancial institutions (King
et al. 2011; Phelan etal. 2018). This is particularly relevant as bank staff often
experience a suspicion of FA of the older person (Phelan etal. 2018). Despite this,
nancial agencies, such as banks, post ofces, credit unions and building societies
may be reluctant to intervene in nancial abuse of older people. Concerns regarding
a breach of privacy, condentiality of the client and defamation of the alleged per-
petrator through reporting the suspected FA have all been identied (Choi etal.
1999; Hughes 2003a, b). It has been noted that having mandatory reporting for
nancial abuse has been challenging to nancial institutions and voluntary report-
ing systems appear more acceptable (Hughes 2003a).
In the context of strategies which are used by banks, reporting programmes
have been very effective in preventing nancial losses (Hughes 2003b). Targeted
education of front line staff and management can alert awareness and action by
such staff in responding to suspected FA, for example, in the case of irregular
banking documents, missing nancial documents and unusual banking activities
A. Phelan
113
(National Committee for the Prevention of Elder Abuse 2008). Moreover, as
banking and money management become more sophisticated, older people may
struggle to adapt to new methods of money management (Conrad etal. 2011). In
an age of technology, new modes of contact (phishing, vishing, and scamming via
the internet) can heighten susceptibility to FA (Crosby etal. 2008). Thus, ensur-
ing equity through human interface is fundamental for people who prefer personal
facilitation with banking activities.
8.10.4 Multidisciplinary Teams
The process of using multi-disciplinary teams to address the FA of older people is
essential as a variety of diverse support and intervention mechanisms may be
required (Kemp and Mosqueda 2005; Reeves and Wysong 2010). Such teams
require elements of an inter-agency framework, a multi-agency management com-
mittee and policy and service audits to oversee the safeguarding service’s co-
ordination (Home Ofce and DoH 2000). Partnerships from diverse disciplines
allow specic areas of expertise to generate comprehensive investigations, responses
and general case management (Reeves and Wysong 2010) and some teams have
incorporated the training of older people themselves as members of response teams
(Response Technical Team) (Nerenberg 2008). More importantly, multi- disciplinary
teams have been shown to increase prosecution rates for FA (Navarro etal. 2012).
One example is the Financial Abuse Specialist Team (FAST) in California (Orange
County), USA.This is a voluntary service which is comprised of diverse profes-
sionals such as adult protective services, law enforcement, legal representatives,
nancial planners and banking representatives. Each month, cases are reviewed and
the varied disciplinary membership has the advantage of providing strategic plans to
resolve nancial abuse (Allen 2008). The FAST also provides specialist training for
police and banking personnel. Despite its success, the establishment of such teams
is limited beyond the United States of America.
8.10.5 Money Management Programmes
Money management is an essential component of independent living (Elbogen etal.
2011) and an important element in independent budgeting (Moran et al. 2013).
Money management programmes have been used to combat nancial abuse
(Nerenberg 2008), particularly as adequate funds are necessary for basic needs such
as food, shelter and so forth. An actual or perceived inability to manage money can
provide a catalyst to involving a third party to manage nancial affairs. Consequently,
money management programs are particularly relevant for older people who have/or
areperceived to be having challenges in nancial capacity or are having difculties
negotiating new technologies regarding banking and nancial affairs. Money
8 Financial Abuse ofOlder People
114
management programs can range from assistance with routine tasks such as paying
bills to more complex tasks such as general budgeting and management of banking
accounts, thus empowering the older person to monitor their funds (Setterlund etal.
2007). Enabling empowerment through money management programs may also be
an important element within personalized budgets, as a cultural change may be
required in relation to being transformed into a care purchasing consumer (Moran
etal. 2013). Moreover, enablinga balance of risk is an important component of
safeguarding and the management of personal budgets (Ismail etal. 2017). One
notable innovation focused on empowering older people was undertaken by the
National Centre for the Protection of Older People in University College Dublin,
Ireland and resulted in a website resource to assist older people in areas such as
bank accounts, making wills, capacity legislation and home security (see chapter by
O’Donnell).
8.11 Conclusion
Prevalence studies demonstrate that nancial abuse of older people is a signicant
public health challenge globally. However, dening the issue is problematic as there
is no current universally agreed understanding. FA is immersed in taken for granted
cultural assumptions, family ties, blurred perceptions regarding its boundaries as
well as requiring a much greater level of inter-sectorial collaboration. Despite hav-
ing a signicant impact on health and welfare of an older person, nancial abuse
has, to date, been under-researched and the capacity to appropriately respond to it is
lacking. It is important that additional research is undertaken in this complex area
and that robust evidence based prevention and intervention inter-sector strategies
are integrated into safeguarding older people against nancial abuse.
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8 Financial Abuse ofOlder People
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A. Phelan (ed.), Advances in Elder Abuse Research, International Perspectives
on Aging 24, https://doi.org/10.1007/978-3-030-25093-5_9
Chapter 9
Keep Control: ACo-designed Educational
andInformation Campaign Supporting
Older People toBeEmpowered against
Financial Abuse
DeirdreO’Donnell
9.1 Introduction
Empowerment is understood as a psychological and social construct. It connects
individual and collective well-being as well as social change with strengths and
competencies, ecological resources, environmental helping systems and networks
as well as direct collective action (Drury etal. 2005; Hur 2006; Zimmerman and
Rappaport 1988). Empowerment encompasses an individual’s self-mastery and
their power to participate and to be involved in the life of their several communities
(Rappaport 1995). This multilevel construct moves between and within individual,
organizational and political levels of analysis. The Cornell Empowerment Group
described a process model of empowerment by which an individual gains greater
access to and control of valued resources (Cochran 1992). This concept of empow-
erment emerged from the economic transformations and social justice movements
of the 1970s. As a result, the practical application of empowerment programs in the
elds of community psychology and social work has been concerned with the dis-
tribution of power and access to resources which are valued by society.
The experience of aging has provided the focus for social and health sciences
research concerned with demographic trends depicting an aging population and the
social, economic, psychological and health resources necessary to enhance quality
of life and well-being in later life (Low and Molzahn 2007; O’Donnell 2011;
Steverink et al. 2001; Wiggins et al. 2004). Feminist gerontology highlighted a
youth-oriented society, which, at best ignored the conceptual interrogation of aging,
and at worst, sustained stereotypes and normative prejudice in marginalizing the old
(Biggs 1999; Biggs and Lowenstein 2003; Calasanti 2003; Calasanti and Slevin
2006). This research indicated the necessity to interrogate concepts such as
D. O’Donnell (*)
National Centre for the Protection of Older People, School of Nursing, Midwifery & Health
Systems, University College Dublin, Beleld, Dublin, Ireland
e-mail: deirdre.odonnell@ucd.ie
122
well- being, quality of life and empowerment from the perspective of older women
and men. In this way, research can reect upon the life course transitions and adap-
tations of older people in order to determine how older people may be empowered
to optimize their resources to meet their priorities and needs and thereby sustain
their well-being and life quality.
Older people’s agency in the context of personal and environmental circum-
stances informed much research which investigated quality of life and well-being in
later life (Higgs etal. 2003; Low and Molzahn 2007; Rozario etal. 2011; Steverink
etal. 2001; Wiggins etal. 2004). Recognition of the role of agency in the optimiza-
tion of resources and the prioritization and attainment of goals in later life has per-
tinence for interventions targeted at preventing and/or managing cases of elder
abuse. Elder abuse is a complex and multifaceted phenomenon which presents ethi-
cal challenges and dilemmas for those managing cases of abuse to reconcile the
autonomy and self-determination of clients with issues of capacity, risk, and vulner-
ability (O’Donnell etal. 2015a). In a study of self-determination in elder abuse,
Bergeron (2006) argued that a social worker’s role in managing a case of elder abuse
is to facilitate appropriate decision-making of an older person by guaranteeing the
availability of choices for intervention. Some of the mitigating factors described by
Bergeron (2006) as impacting older people’s decision-making included environ-
mental and family circumstances, life course experiences, health, and cultural fac-
tors. The study underscored the availability of resources in cases of elder abuse
which would provide realistic alternatives and facilitate an older person to choose a
particular intervention to end circumstances of abuse.
Despite increasing recognition of the epidemic of elder abuse, there is a lack of
robust evidence to support any particular intervention to prevent or address abuse
(O’Donnell etal. 2015b). It is generally agreed that elder nancial abuse is under-
reported and is particularly difcult to recognize or detect. This form of elder abuse
is often concurrent with, and indicative of, other types of abuse particularly dis-
criminatory and/or psychological abuse. Anand and colleagues (2011) undertook
participatory qualitative research with older people in Ireland, in which they
explored older people’s understandings of abuse. The ndings of this study indi-
cated a new concept of ‘personhood abuse’, which referred to the effects of societal
ageist attitudes on an older person’s condence, autonomy, and agency. The study
highlighted abuse preventative interventions which addressed the repercussions of
this attitude that included: awareness and information-raising, peer support, com-
munity engagement activities and enhancing personal, social and collective
resources.
In summary, at the core of best practice interventions which seek to maximize
older people’s well-being and reduce their vulnerabilities to any form of abuse is
recognition of older people’s agency. Fostering and protecting the agency of the
older person and empowering them to optimize their strengths and resources under-
scores best practice in social and health care interventions for older people (Mulligan
etal. 2012; Shearer etal. 2012). These practices are informed by the necessity of
optimizing strengths and resources to attain the goals and priorities of the older
person. This strengths-based perspective is in line with conceptualizations of
D. O’Donnel l
123
empowerment as well as social-gerontological and feminist discourse, which are
concerned with the redistribution of interpersonal power, social justice, and change.
9.2 Keep Control
This chapter provides a description of the Keep Control campaign. This intervention
resulted from a process of authentic and meaningful collaboration between repre-
sentatives of older people and academic researchers from the National Centre for
the Protection of Older People (NCPOP) in University College Dublin. The project
and intervention were funded by the Irish Health Service Executive (HSE). Keep
Control is a strengths-based preventative intervention which celebrates, protects
and fosters the agency and resources of older people. It supports older people to
safeguard themselves from nancial abuse.
9.3 Research Design
The Older People’s Empowerment Network (OPEN) was established at the com-
mencement of the project to co-design and develop the Keep Control intervention.
OPEN is a network of representatives of older people and researchers who are
engaged and involved with academic research related to the health and social well-
being of older people in Ireland. The co-design approach adopted for this project
adheres to principles of democratic active participation and dialogue in collabora-
tive research (O’Donnell etal. 2016).
9.4 Co-design Collaborator Recruitment
Five collaborators were recruited to OPEN from the membership of Non Government
Organizations (NGO) and community-based advocacy organizations working with
older people. These were older people willing to share their expertise and knowl-
edge in relation to the experience of aging. Two academic researchers (including a
research assistant) also joined the team. An academic researcher co-chaired each of
the co-design meetings with one of the older people representatives who were
invited to co-chair on a rotating basis. The academic chair facilitated the collabora-
tive work and acted as a point of contact for all co-design members.
The academic chair also convened a panel of nine advisors who had professional
interests and expertise in vulnerable adult safeguarding as well as in nancial pro-
tection. This included: two solicitors with expertise in relation to older person safe-
guarding and nancial abuse; a member of An Gárda Síochána (Irish Police Force)
with a specialist role in community policing and nancial abuse prevention; two
9 Keep Control: ACo-designed Educational andInformation Campaign Supporting…
124
members of the Irish state’s Money Advice and Budgeting Service (MABS); the
Health Service Executive’s Dedicated Ofcer for the Protection of Older People; a
senior social worker with a specialist role in adult safeguarding; a branch bank man-
ager with an interest in adult nancial abuse prevention and a member of the Health
Services Executive’s Services for Older People. These experts were invited to attend
co-design meetings on a rotating basis to guide the collaboration and to share their
specialist knowledge. Furthermore, they contributed to the intervention develop-
ment by reviewing the intervention at the draft stage and providing feedback in
relation to accuracy and accessibility. The advisors also provided access to resources
for reproduction or assimilation into the intervention.
9.5 Designing Meaningful Collaboration
The methodological approach adopted for this co-design work was supported by
ve enabling factors ensuring democratic, meaningful and authentic public involve-
ment (O’Donnell etal. 2016). These factors were:
1. engaging active participation from the earliest point possible in the process of
intervention development;
2. establishing a co-design team (OPEN) with a critical mass of public representa-
tives and which is organized in a non-hierarchical manner;
3. having a dened objective with designated deliverables which are discussed and
agreed upon by the co-designteam from the outset of project development;
4. ensuring there is adequate knowledge exchange between co-design members
and ensuring that professional knowledge is transferred and disseminated
throughout the team in an accessible way and nally;
5. activating the public representatives as the ‘public faces’ of the initiative for the
purposes of implementation and dissemination.
9.6 Co-design Procedures
Eleven co-design meetings were held with the OPEN group between July 2013 and
September 2014. These were structured collaborative workshops which ensured
that the resulting empowerment intervention was person-centred, targeted to the
needs and priorities of older people and accessible (Table9.1). Detailed notes of
each of the meetings were taken by a research assistant and disseminated prior to
each workshop.
The rst two meetings were designed a priori and were focused on capacity
building for the team. The purpose of this capacity building was developing a com-
mon understanding of later life empowerment from which to collaboratively build
the safeguarding intervention. It was important to center the collaborations on the
D. O’Donnel l
125
Table 9.1 Structural overview of the 11 co-design workshops
Workshop Theme Content
Workshop
one
A-priorydesign for
capacity building:
Later life
empowerment
Introductions, project familiarity and agreement of terms of
reference for co-design participant roles and objectives.
The academic chair presented a model of later life
empowerment which was developed from previous
inductive grounded theory analysis of focus group data
collected from older people, NGO community advocates
and representatives of older people as well as senior case
workers responsible for managing cases of elder abuse.
The co-design group discussed the conceptual model and
identied the component elements and outcomes from
empowerment. This provided a theoretical and conceptual
background to the collaborative work.
Workshop
two
A-priory design for
capacity building: The
voice of elder abuse
survivors
The voice of elder abuse survivors was represented in the
co-design group through a secondary analysis of qualitative
data collected from semi-structured interviews with nine
survivors. The qualitative data were re-analyzed using a
coding framework representing the model of
empowerment. The data was presented to the group in such
a way as to describe the journey from abuse to survival.
The group’s attention was drawn to the interpersonal and
intrapersonal resources for survival which were featured in
the survivors’ stories.
Workshop
three
Resources for nancial
control (MABS)
Presentation from an expert advisor from the states money
advice and budgeting service (MABS) followed by group
discussion of the MABS resources in relation to nancial
safeguarding.
Workshop
four
Review of legal
aspects of nancial
abuse.
Presentation from legal expert advisor (former law reform
commissioner) with a discussion of some recent legal
cases.The discussion highlighted issues involved inthe
nancial abuse of older peopleincluding undue inuence
and unconscionable bargains. Therewas also discussion of
vulnerabilities posed by joint account banking
arrangements.
Workshop
ve
Brainstorming the
intervention
Brainstorming session with the group for planning
intervention components. Identied core principles of the
intervention as including: Retaining autonomy, staying in
control, responsibility, respectful consultation. It was
agreed the interventions should be targeted towards
prevention.
Workshop
six
Review of intervention
exemplars. The
perspective of a social
worker on nancial
abuse of older people
Review of some existing interventions related to nancial
literacy (MABS), education and planning (think ahead,
Teagasc), security (Garda– Public awareness campaign).
The group discussed how the strengths of these
interventions could be translated into the developing
intervention. Presentation from a senior case worker
responsible for managing cases of elder abuse. Discussion
of the psycho-social aspects of nancial abuse.
(continued)
9 Keep Control: ACo-designed Educational andInformation Campaign Supporting…
126
lived experiences of elder abuse survivors. Therefore, the capacity building also
allowed for discussion of the intrapersonal and interpersonal resources for later life
empowerment evidenced in the testimonies of survivors. The subsequent eight
meetings were thematically organized; as per the requirements of the project and the
agreement of the team members. Where relevant, advisors were invited into work-
shops to share knowledge and expertise (Table9.1).
9.7 Results
Keep Control is a multi-media educational campaign which provides information to
older people necessary for their self-protection from nancial abuse. The campaign
consists of three pillars for the dissemination of information and resources neces-
sary for older people to safeguard their nances. These pillars are a website, a DVD
and an information pack containing Keep Control resources.
Table 9.1 (continued)
Workshop Theme Content
Workshop
seven
Mapping the
intervention
components
Mapping the proposed intervention content. Agreement on
the topic areas for focus and the three intervention
components (website, DVD and resource pack). In-depth
discussion of the website layout and principles for design:
Accessibility and user-friendly, colors and audio
transcription for readability, positive images of older
people in their everyday lives. Intervention text content was
reviewed and suggestions for edits were made. Title of the
intervention was agreed: Keep control
Workshop
eight
Planning the DVD Discussion of the DVD content and agreement on design
principles. Target audience to be older people and will be
delivered by older people talking directly to other older
people. Review and agreement of the script.
Workshop
nine
Reviewing the
intervention text
content (website and
resource pack)
Review of the content for three of the intervention
component areas: Opening a joint account, creating a will,
assisted decision-making. Feedback to the group as to the
review comments from the panel of expert advisors.
Workshop
ten
Review of three
intervention
components
Review of the website with discussion and feedback on any
suggestions for modication etc.
Review of the draft videos for the DVDwith feedback for
nal edits and revisions.
Review of the information pack content including
thetoolkit resourceswith feedback for nal edits and
revisions.
Workshop
eleven
Dissemination Final review and feedback on the three intervention
components. Agreement of the dissemination plan and
intervention launch.
D. O’Donnel l
127
9.8 The Keep Control Website
The Keep Control Website is the main access point to information and resources
which enable older people to empower themselves against nancial abuse. In addi-
tion, the video content that was developed for the campaign is embedded into the
website. This content features older people empowering themselves in situations
where they may be vulnerable to nancial abuse by taking preventative measures.
The website provides an outlet for community exchange of information and
resources. It is connected to social media networking sites including A Keep Control
Facebook and A Keep Control Twitter Account. These platforms allow older people
and those interested in the campaign to engage with key issues and topics around
elder nancial protection as well as generating opinions and discussions around the
topic.
The website follows guidelines for accessibility and disability access. This
includes the use of high-contrast colors and an accessible font (Verdana).
Furthermore, there is a large text option on the site which allows users to increase
font size. There is also access and instructions for the use of open-source software,
designed to enable users with a visual impairment to access web-content. The web-
site contains photos in order to enhance its visual appeal. Many of the photos are of
the actors who feature in the DVD thus creating consistency in terms of branding
between the different formats of the intervention.
The content of the website has been structured in such a way as to enable users
to navigate it using minimal scrolling. This is to ensure that the links outlining the
ow of information are visible and easily accessible at all times. The user may
access the main sections of the website through a tab bar which is located at the top
of the webpage and which is visible on each page of the site. Each section is seg-
mented into smaller units and subunits of information with their own individual
page. The user navigates this information through a drop-down menu on the left-
hand side of the screen while links to subunits are also displayed at the bottom of
the page. At all times a breadcrumb trail appears horizontally across the top of the
webpage, just below the main tab-bar. This allows the user to keep track of their
location within the website and there are links back to each previous page the user
navigated.
The homepage of the website contains a welcome section which introduces the
Keep Control campaign and provides an overview of the site. A link to the Keep
Control video content is available and can be accessed by clicking on a screen-shot.
The video content is hosted off-site in order to ensure minimal disruption to the
website which may be caused by storing large video/audio les. The information
pack, including the tools and resources, which were co-designed for the campaign
are also available to view and download from the site.
The website information includes a section on Financial Abuse which provides
the user with a description of what nancial abuse is, including the different types
of nancial abuse; warning signs of abuse; typical perpetrators and a discussion of
what to do if one suspects nancial abuse. The main intervention information
9 Keep Control: ACo-designed Educational andInformation Campaign Supporting…
128
content is located in the Keep Control section of the website. This content is divided
into ve areas:
1. Making a Will
2. Enduring Powers of Attorney
3. Joint Accounts
4. Decision-making at Critical Life Events
5. Protecting myself on my Doorstep
Each of the ve content areas is broken down into smaller units of information
which provide information related to what each content element is and why they are
being encouraged to safeguard themselves in relation to each element. Furthermore,
they are provided with area-specic guidelines for empowerment and self- protection
as well as warning signs of potential abuse which are specic to the content area. It
was agreed by the OPEN co-design team that modeling appropriate language,
behavior and dialogue would be important for enabling older people’s empower-
ment. Therefore, each of the content areas included a sub-section called ‘we need to
talk: conversation tips and starters’. This sub-section included exemplary language
and advice for conversation planning and preparation. For the most part, this advice
was tailored to assist the older person to plan potentially difcult or challenging
conversations in such a way as to minimize the risk of conict. This was comple-
mented by a content-specic video which was embedded into the website which
modeled these conversations and dialogues.
9.9 The Keep Control DVD
The Keep Control DVD was developed by the OPEN co-design team as the second
pillar of the campaign. It is composed of seven video segments each of which are
embedded into the website to accompany the corresponding information (Table9.2).
The DVD was also included in the hard copy information packs. It features older
people in ve different scenarios where they are vulnerable to the risk of nancial
abuse. These scenarios correspond to the ve content areas of the website. In these
scenarios, the older person may be subjected to subtle intimidation, be placed under
undue inuence or may fail to take responsibility for their affairs.
The DVD shows an older person acting out two different endings in ve different
scenarios. In one ending the older person is empowered and self-protects from
potential nancial abuse by following the guidelines and recommendations outlined
in the Keep Control campaign. In the other ending, the older person doesn’t follow
the guidelines and as a result, becomes vulnerable to nancial abuse. The scenario
pauses at the point where there is a potential for the older person to become vulner-
able. At this point, the older actor turns to the camera and outlines the two options
that he/she has. The viewer can then choose to select option 1 or option 2. If the
viewer selects option 1, they will see the older person acting out one ending. If the
D. O’Donnel l
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Table 9.2 Seven DVD content areas
Video Theme Content
What is elder
nancial abuse?
Keeping control
of your nances
This is an introductory video which outlines what elder nancial abuse is and
gives examples of crimes and subtle forms of nancial abuse. An example of
nancial abuse follows. This example shows an older woman being intimated
by her son who appears to have a drinking problem and who takes her money
without her permission and does not use it to benet her. The closing scene of
this video explains the aims and key messages of the keep control campaign
and directs people to visit the keep control website to nd out more
information.
Making a will:
Keeping control
of your
possessions
In this video, an older woman decides it’s time for her to make her will and
her son puts some pressure on her to see his solicitor. Option one shows her
accepting her son’s offer and the pressure she faces as a result. Option two
shows her insisting that she see her own solicitor and demonstrates her
protecting herself from abuse by recognizing and resisting undue inuence
and following the guidelines for making a will which include getting
independent legal advice. It demonstrates the older woman negotiating the
details of her will with her solicitor. The video closes with the older person
giving advice to viewers on how to protect themselves when making a will
and the important things to remember.
Enduring power
of attorney:
Keeping control
of your
decision-making
This video underlines the importance of setting up an an enduring power of
attorney (EPA). This is a legal decree, set up by a person with decision
making capacity to protect their will, preference, values and beliefs in the
event he/she loses decision-making capacity and is unable to manage their
affairs. The video also demonstrates the challenges that families may
encounter when an EPA is not in place and a close family member suddenly
loses decision-making capacity. In this video, an older man and his daughter
talk about an EPA.His daughter thinks it’s a good idea to set one up but the
older man is not so sure. The video demonstrates two options. In the rst
option, the older man decides against setting up an EPA and later develops
dementia which makes it very difcult for his family to manage his affairs. In
the second option, the video demonstrates the older man going through the
process of setting up an enduring power of attorney by meeting with his
solicitor. The video closes with the older person giving advice to viewers on
how to protect themselves when setting up an EPA and the important things to
remember.
Opening a third
party account:
Keeping your
nances secure
This video demonstrates the circumstances in which it may be appropriate to
set up a third-party account and the best procedures to follow when doing so.
In this video, an older man and his daughter think about how she could
withdraw money from his account to help him with shopping. The older man
nds out what they should do and suggests that the two of them visit the bank
to nd out more. Once there, the bank conrms that the older man can allow
his daughter to access his account by making setting up a third-party account
and making her an authorised signatory. The older man has two options at this
point. Option one is to set up the account without giving any thought as to
how he wants it to work thereby risking losing control of the account. Option
two is to give instructions to the bank about how the third party account
should work thereby allowing him to keep control over the account. The video
closes with the older person giving advice to viewers on how to protect
themselves when setting up a third-party account and the important things to
remember.
(continued)
9 Keep Control: ACo-designed Educational andInformation Campaign Supporting…
130
viewer selects option 2, they will see the older actor acting out the other ending. The
viewer will also be able to view both options to see different endings.
The idea of demonstrating two different routes or scenario endings was gener-
ated from discussions among the co-design group. It was agreed that pausing the
video at a particular junction in the scenario, would emphasize to the viewer that
there is often a decision point in which an older person can self-protect and demon-
strate empowerment which may prevent their vulnerability to abuse. Furthermore, it
was felt among the group that the videos would demonstrate the behaviors and
language of empowerment for viewers thereby modeling the advice provided by the
content areas of the website or information pack within specic contexts.
9.10 The Keep Control Information Pack
It was agreed by the OPEN co-design team that in order to maximize the reach of
the Keep Control campaign an information pack would be developed providing a
physical hard copy of the campaign material. This information pack complements
the electronic content (website and videos) and ensures that the campaign reaches
older people who are not familiar with accessing information online. The Keep
Control Information Pack is the third pillar of the intervention and includes an infor-
mation booklet, a DVD as well as physical copies of the campaign resources.
Table 9.2 (continued)
Video Theme Content
Decision-
making at
critical life
events: Keeping
control at
critical times
This video shows an older man who has been diagnosed with a terminal
illness. The older man has two options in this video. One option is to take
each day as it comes and not to plan ahead while the other option is to start to
make end-of-life arrangements. The video demonstrates the importance of
putting your affairs in order as soon as possible and in the closing of the video
the point is reinforced by the actor who advises viewers about how to keep
control at critical life events.
Doorstep
security:
Keeping control
of your safety
The video underlines the importance of exercising caution with cold callers
andhighlights important checks which should be performed. The video
depicts a cold caller calling to an older person’s home. The caller claims to be
from a charity and asks the older person for their bank details. The older
person has two options. Option one show the older woman giving the caller
her bank details without performing any checks. This places the older woman
at risk of nancial abuse. The second option shows the older woman
performing checks to verify the caller’s identication and calling the
policeupon discovering that the caller is not legitimate. The video closes with
the older woman reminding viewers of the checks that they should perform to
protect themselves on their doorstep.
What do I do if
I suspect abuse?
This video provides information to viewers on who to contact if they suspect
that they themselves, or someone they know, is being nancially abused. The
video directs the viewer to the keep control website as well as highlighting the
HSE helpline number throughout.
D. O’Donnel l
131
The Keep Control booklet corresponds directly to the website in terms of the
structure and information content. The design of the booklet echoes the website and
DVD in relation to logos, color scheme, images, and content. The booklet adheres
to accessibility guidelines (font size, contrast etc.). There is an introductory section
which provides an overview of nancial abuse in general and this is followed by
more detailed information on the ve content areas as well contact information and
advice for responding to suspicions of abuse.
Campaign resources which were developed by the OPEN co-design group in
consultation with the expert advisory panel were included in the information pack.
These resources are also available for downloading from the website. The resources
include the Keep Control videos, a nancial planning and budgeting guide, a safe-
guarding door handle promoting security in the home, a window sticker to prevent
cold callers and scammers, a calling card to deter door-stepping as well as a poster
and a campaign ier. The iers and posters advertise the Keep Control campaign
and direct people to visit the Keep Control website. The iers also list the top ten
tips for protecting oneself against nancial abuse.
The budget planner facilitates older people in interacting with family members
and/or other household members by providing them with a resource to ensure trans-
parency and fairness in managing shared household expenses. The door handle can
be placed inside an older person’s front door. The handle provides space to record
important phone numbers, including emergency contact details and provides
reminders of the top tips for safeguarding from bogus callers. The purpose of the
window sticker is to assist the older person (or any member of the public) to main-
tain their doorstep security. The sticker can be placed in the window at the front of
the house notifying a caller that the person does not want cold callers and does not
buy and sell on the door. It also tells callers that they must be able to present veri-
able identication. Calling cards are also provided in the pack, these are intended to
be used by the older person to manage cold callers to their door. On one side of the
card, the older person is reminded of important things to remember when a cold
caller comes to the door. On the opposite side of the card is space for contact details.
The older person can hand this cardto a caller and ask them to ll in their contact
details. The card allows the older person to consider whether they wish to engage
with the caller and if so they can be in control of how to initiate this contact.
9.11 Dissemination
The dissemination of the campaign commenced with an intervention launch by a
Government minister with responsibility for disability, older people, equality and
mental health. The OPEN co-design group was promoted at the launch as the archi-
tects of the campaign and the public faces for dissemination. This launch was com-
plemented by a national ‘roadshow’ of seminars among local community groups,
active retirement groups and other community-based support networks for older
people. A total of 16 seminars were held across eight national regional departments.
9 Keep Control: ACo-designed Educational andInformation Campaign Supporting…
132
The focus of these seminars was for the OPEN co-design members to disseminate
the campaign and to train older people to facilitate the engagement of their com-
munity peers with the intervention content. This provided the basis for downstream
cascading of the information through local champions. In addition, approximately
2000 information packs were disseminated to local libraries and community centers
nationwide.
9.12 Discussion
Empowering processes are those actions and programs which enable people to gain
control over valued social resources and to leverage those resource to make or inu-
ence decisions that affect their quality of life and well-being (Perkins and
Zimmerman 1995). Previous research and theorizing from the elds of health psy-
chology and community empowerment have indicated that successful empower-
ment processes facilitate community members to develop skills that increase their
independence from professionals (Dowling etal. 2011). Empowerment processes
targeting the wellbeing of older people should include the transfer of knowledge
and skills for self-care and decision-making as well as the recognition and develop-
ment of intrapersonal and interpersonal resources for optimizing well-being (Chapin
and Cox 2002; Fisher and Gosselink 2008). The strengths-based perspective of the
Keep Control campaign emphasizes the sources of life strength as well as capacities
for resilience in later life rather than decit management focusing on vulnerability
or risk. In this way, the campaign is an empowering process which promotes the
agency of older people and recognizes their abilities to safeguard their well-being
through fostering their intrapersonal and interpersonal strengths.
A signicant feature of the Keep Control campaign, which further characterizes
it as an empowering process, is the involvement of community members in the
development, implementation, and dissemination of the intervention. The process
for co-designing the intervention was grounded in a partnership based on equality
between target community members, academic researchers, and professionals. This
participative process, by which target communities are encouraged to interpret their
situations and identify the intervention outcomes, is noted as being critical to suc-
cessful, meaningful and authentic empowerment (Chapin and Cox 2002; Fisher and
Gosselink 2008). Designing meaningful collaboration in the co-design process was
central to the success of the Keep Control campaign as it ensured intervention
authenticity. Furthermore, it encouraged receptivity among the target community; it
was an intervention for older people developed and delivered by older people. This
was a central feature of the campaign dissemination which encouraged local Keep
Control champions to disseminate the intervention content among their peers.
D. O’Donnel l
133
9.13 Conclusion andLimitations
The fostering of agency over valued resources is critical to a concept of empowered
aging which seeks to promote active participation in processes of resiliency and
self-protection. Keep Control is a resource for all older people living in Ireland and
also for people interested in elder nancial abuse protection. It provides information
and resources to support older people to be empowered against nancial abuse and/
or exploitation. This is underscored by an understanding that empowerment occurs
when an individual takes responsibility for their own protection by keeping control
over their affairs and ensuring that their decisions, wishes, and intentions for their
nances are respected and followed. The Keep Control campaign aims to empower
older people with competencies, skills, and knowledge which facilitate choice, self-
determination and assertive interpersonal interactions. In this way, an older person
can open themselves to processes of empowerment in safeguarding their nances
and their well-being in later life.
9.13.1 Limitations
Capacity building and the empowerment of elder abuse survivors to engage with
academic research and intervention co-design is necessary. The requirement to
build capacity for meaningful, empowering and democratic participation mitigated
against the inclusion of elder abuse survivors on the co-design team for this study.
A decision not to include those with direct experience of elder abuse was taken out
of consideration of the potential to do harm. This harm could arise from repeated
retelling or reliving of their abuse story. However, the lack of survivors’ voices in
co-design team is a considerable limitation of the study. This was offset through the
inclusion of a secondary analysis of qualitative data collected from nine survivors
which was presented to the co-design team. The purpose of this analysis was to
center the co-design work on direct experiences of surviving abuse and was pre-
sented through the lens of empowerment theory.
Sustainability of the campaign beyond the lifetime of the project funding is a
challenge and a further study limitation. This has been offset by the development of
the OPEN co-design team who have continued to engage with the intervention con-
tent and dissemination. Furthermore, the dissemination of the intervention encour-
aged the development of local and regional Keep Control champions nationwide.
However, ongoing coordination of the dissemination activities and maintenance of
the online content in the absence of sustained funding continues to be a challenge.
This challenge can only be offset through the commitment of organizational and
policy leaders as partners with regards to intervention maintenance and
dissemination.
9 Keep Control: ACo-designed Educational andInformation Campaign Supporting…
134
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A. Phelan (ed.), Advances in Elder Abuse Research, International Perspectives
on Aging 24, https://doi.org/10.1007/978-3-030-25093-5_10
Chapter 10
Elder Abuse andDementia
ClaudiaCooper andGillLivingston
10.1 Introduction
Globally, about 47 million people were living with dementia in 2015, and this num-
ber is projected to triple by 2050 (Livingston etal. 2017). People with dementia are
particularly vulnerable to abuse (McCausland etal. 2016), probably because they
are more likely to depend on others for care, and to have impairments in memory,
communication abilities and judgment that make it more difcult for them to avoid,
prevent and report abuse. Many are reluctant to report abuse perpetrated by those on
whom they depend. Because people living with dementia are less able to care for
themselves, they are also more at risk of self-neglect, which is dened as elder
abuse in some jurisdictions, including the USA (United States of America). In a
study of USA Adult Protective Services (APS) cases, cognitive impairment was
signicantly associated with self-neglect in older people (Choi etal. 2009). Ninety
percent of patients with dementia develop neuropsychiatric symptoms at some point
in the illness (which include agitation, aggression, depression and apathy) (Ballard
and Oyebode 1995), and these symptoms are associated with an increased risk of
abuse, probably because it is more difcult to care for a person who is experiencing
them. The consequences of abuse include distress, physical and mental ill- health,
hospitalization, reduced survival, institutionalization and nancial loss (Dong and
Simon 2013; Dong etal. 2011, 2013). People with dementia are probably particu-
larly vulnerable to these adverse consequences, because they already have worse
physical and mental health, and are at greater risk of mortality, hospitalization and
institutionalization.
In this chapter, we will rst discuss the particular challenges of detecting abuse
in people with dementia. We then review the evidence regarding the prevalence of
elder abuse in people with dementia and discuss possible risk factors for it, before
C. Cooper (*) · G. Livingston
UCL Division of Psychiatry, London, UK
e-mail: claudia.cooper@ucl.ac.uk
138
exploring what we know about how to reduce and prevent abuse in this population.
The people with dementia that have contributed to the research studies presented
had by denition, received a dementia diagnosis and the opportunity to take part in
research. People from marginalized groups, including those living in areas of depri-
vation and who are from Black and Minority ethnic groups, are less likely to be
diagnosed and to take part in research; so these groups may be relatively less repre-
sented in the evidence base presented (Cooper etal. 2014; Cooper etal. 2010a, c).
The act of abuse does not imply intent, and in many cases the carers may not have
viewed their own actions in this light.
10.2 Detecting Elder Abuse inPeople Living withDementia
Estimates of the prevalence of elder abuse are likely to be inuenced by the inability
of many people with dementia experiencing abuse to remember and report it, and
the fear and embarrassment they may experience in doing so. A wide range of prev-
alence gures are reported in people with dementia, possibly because of the differ-
ent populations studied and the methods used to measure abuse (Cooper et al.
2008a; Dong 2015). While health care professionals who suspect or have evidence
of abuse will ask people with dementia for their perspective of whether they feel
safe, or have fears, or recall abuse and many people with dementia can give an at
least partial account of their experiences, we have limited evidence about how many
people with dementia would report abuse if asked. Only one research study, to our
knowledge has asked older people with dementia to self-report abuse. In a USA
study involving 254 family carers and 76 older people living with dementia, 17.2%
of carers reported perpetrating violence, and 26.1% of older people reported expe-
riencing violence (Vandeweerd etal. 2013).
In clinical practice, abuse is generally detected by staff working with older peo-
ple asking about it directly, and being alert to possible signs of abuse such as fear,
an older person appearing to lack basic necessities or having unexplained bruises.
Research studies have made a case for screening people with dementia for abuse in
clinical services, through routinely asking family carers, and people with dementia
if they are able (Cooper etal. 2009a), but this does not happen routinely in practice
in most settings. Some studies have used a vignette about a ctional person with
dementia being cared for by her son who uses a range of care strategies, some of
which met widely accepted denitions of abuse. They have demonstrated that pro-
fessionals, family carers, home carers, medical students and other professionals fre-
quently do not agree about what constitutes abuse. For example, locking the person
with dementia in the house all day while her son went to work, would universally be
considered abusive in policy, because it would not be the least restrictive option to
keep her safe and she would be unable to get out in an emergency; but many of the
respondents in the research studies did not agree this was abusive (Caciula etal.
2010; Hempton et al. 2011; Selwood et al. 2007; Thompson-McCormick et al.
2009). Only a third of health care professionals working with older people reported
C. Cooper and G. Livingston
139
that they had detected a case of elder abuse in the last year (Cooper etal. 2009b).
Around a quarter of vulnerable older people report abuse when they are asked about
it (Cooper etal. 2008a). Together these ndings suggest that detected and reported
abuse cases are probably the tip of the iceberg.
Abusive behavior exists on a spectrum and the level of abusive behavior that puts
a person at risk of signicant harm and therefore requires reporting to the appropri-
ate authorities requires careful consideration of contextual factors. The capacity of
the person with dementia to decide whether or not to accept help should also be
carefully considered. Where a person with dementia has capacity to make the deci-
sion about continuing in an abusive relationship or situation, professionals should
carefully consider how to mitigate risks as far as possible, for example, through
regular review (because dementia is a degenerative condition) discussing ways of
coping with the person who is abusing and delineating clear, simple processes for
accessing help. People with dementia with capacity will nonetheless be vulnerable
and the likelihood that a decision to decline help was made under duress, and the
possibility that other people may be at risk from the abuser must also be
considered.
10.3 Prevalence andRisk Factors ofAbuse inPeople Living
withDementia intheCommunity
A systematic review of six studies reported the overall past year median prevalence
of physical and psychological abuse towards people with dementia as 11% and
19%, respectively (McCausland etal. 2016). Of the six studies surveyed, ve used
carer reports and one an objective measure of abuse. These objective measures of
abuse, which look for signs of abuse such as a person being fearful, or having cuts
or bruises, are less sensitive than self-report measures (Cooper etal. 2008a). In the
carer-report study rated as highest quality, family carers of people with dementia
referred to older people’s mental health team services in London (UK) and the sur-
rounding area were interviewed. Nearly half of the carers reported an abusive act(s)
over the last 3 months, using the Modied Conict Tactics Scale, and a third reported
that abusive acts were happening “at least sometimes” (Cooper etal. 2009a). In the
study that used an objective measure of abuse, which was rated as being of higher
quality, Friedman etal. (2011) analyzed cases of physical abuse and matched con-
trols admitted to trauma centres. Dementia was more common among cases where
elder abuse was suspected compared with controls (Friedman etal. 2011).
A couple of large studies have used the Minimum Data Set for Home Care
(MDS-HC) abuse screen, an objective measure, to report correlates of abuse in people
receiving home care services. In the largest European survey of home care recipients
to date (4000 people aged 65+ receiving health or social community services) those
screening positive for abuse were more likely to be cognitively impaired, depressed, to
have delusions, and to be actively resisting care (Cooper etal. 2006). In a study which
used this screen with 701 people aged 60 and older seeking home and community-
10 Elder Abuse andDementia
140
based services in Michigan between November 1996 and October 1997, participants’
alcohol abuse, psychiatric illness, and short-term memory problems were signicantly
associated with the signs of potential elder abuse (Shugarman etal. 2003).
In a systematic review of studies involving people with and without dementia,
elder abuse has been consistently linked to greater impairments in cognitive and phys-
ical functioning, and with behavioral and psychological symptoms. It has also been
associated with fewer social protective factors, such as, lower social support, socio-
economic disadvantages and being from a minority ethnic group (Dong 2015). In a
study that explores risk factors for abuse reported by family carers towards people
with dementia, more anxious and depressed carers reported perpetrating more abuse;
this relationship was mediated by using dysfunctional coping strategies and higher
burden. Abuse was also predicted by: spending more hours caring, experiencing more
abusive behavior from care recipients and higher burden (Cooper etal. 2010b).
10.4 Prevalence andRisk Factors ofAbuse inPeople Living
withDementia in24hour Care
One third of UK people with dementia live in care homes and at least two thirds of
care home residents have dementia (Knapp etal. 2007). Most care home residents
have dementia and rely on others for personal care and many exhibit challenging
behaviours, factors associated with higher risk of abuse (Cooper etal. 2008a, b).
Carer stress in home staff is associated with: low job satisfaction, long hours, low
pay, physical demands, staff shortages and minimal education and training (Cohen
and Shinan-Altman 2011; Castle et al. 2015) and lower empathy which may be
linked to lower care quality (Astrom etal. 1990). As has been observed in family
carers, experiencing violence and aggression from people with dementia may pre-
dict acting abusively, if staff react defensively or nd managing aggression stress-
ful. This could explain why people with dementia who have more neuropsychiatric
symptoms are at increased risk of abuse (Cooper etal. 2010a). In addition, while
family relationships may be difcult and challenging, the family member caring
usually has a knowledge and understanding of the person with dementia that pre-
dates the dementia and frequently a loving relationship. By contrast, the profes-
sional carer may only have known the person since they developed dementia, and
thus may have less understanding of the person behind the illness. This can contrib-
ute to a decrease in empathy and respect for that person’s humanity, thus removing
social and emotional barriers to acting abusively.
To nd out more about the situations that arise in care homes which may be
linked to abuse, researchers held qualitative focus groups with 36 care home work-
ers that looked after people with dementia in London. The participants reported that
situations with potentially abusive consequences were a common occurrence, but
deliberate abuse was rare. They gave examples of common potentially abusive or
neglectful situations: residents waited too long when asking for help for personal
care, or were denied care they needed to ensure they had enough to eat, were moved
C. Cooper and G. Livingston
141
safely or were not emotionally neglected. Some care workers acted in potentially
abusive ways because they did not know of a better strategy or understand the resi-
dent’s illness; care workers made threats to coerce residents to accept care, or
restrained them; a resident at high risk of falls was required to walk as care workers
thought otherwise he would forget the skill. Most care workers said they would be
willing to report abuse anonymously (Cooper etal. 2013).
Professionals working with people with dementia have reported high rates of
abusive behavior. In one survey, a quarter of relatives of care home residents reported
incident(s) of physical abuse (Schiamberg etal. 2012). In a study that used a valid
and reliable measure to examine elder abuse by professionals, 16% of a random
sample of nurses and care attendants who had been working at one of several long
term care facilities in Taiwan for 6months or longer, reported committing signi-
cant psychological abuse (Wang 2005). Other studies have shown that approxi-
mately 80% of nursing home staff have observed abusive behavior in the last year
(Pillemer and Moore 1989) but only 2% of these cases are reported to the home
management (Jogerst etal. 2012). This suggests that, unsurprisingly, professional
carers are reluctant to report abusive acts, probably because doing so would have
potential adverse legal, employment and social consequences.
Because of this, recent surveys have elicited care worker experiences anony-
mously. In an Israeli study of 510 care staff completing an anonymous questionnaire,
just over half admitted abuse and 70% had witnessed maltreatment in the past year;
more abuse was reported by staff who experienced more burnout and worked in
larger facilities with higher staff turnover (Natan etal. 2010). In a small UK survey
in 5 nursing homes, most respondents (n=138, 88.5%) reported witnessing or sus-
pecting abuse in homes where they had previously worked (Moore 2017). In both
these surveys, staff were asked to identify incidence of ‘abuse’ or ‘maltreatment’, so
behaviors not identied correctly as abusive actions were undetected. However,
many professionals do not correctly identify abusive behaviors (Selwood etal. 2007).
In the largest UK survey of abuse in care homes to date, 1544 staff in 92 English care
home units completed a revised version of the Modied Conict Tactics Scale, adapted to
include specic abuse and neglect items care workers had identied in previous, qualitative
research (Cooper etal. 2013). Unlike in previous surveys, care workers were not required to
identify whether behaviors occurring were abusive or not. They were asked how frequently
a series of positive and potentially abusive behaviors were happening (to their knowledge)
in the care home. 763 (51%) of care home staff reported carrying out or observing poten-
tially abusive or neglectful behaviors at least sometimes in the preceding 3 months; and
some abuse was reported as happening ‘at least sometimes’ in 91/92 care homes. Neglect
was most frequently reported and the most commonly reported neglectful behaviors were:
making a resident wait for care (26%), avoiding a resident with challenging behavior (25%),
giving residents insufcient time for food (19%), and taking insufcient care when moving
residents (11%). In contrast, only 1.1% of staff reported seeing or perpetrating physical and
5% verbal abuse. More staff reported abusive or neglectful behavior in homes with higher
staff burnout-depersonalization scores on the Maslach Burnout Inventory. The authors con-
cluded that anonymous reporting of abuse by care home workers is acceptable and feasible,
and it could be useful indicator of care home quality (Cooper etal. 2018).
10 Elder Abuse andDementia
142
The best available evidence for institutional characteristics associated with abuse
comes from inquiries conducted into abuse scandals. Prominent inquiries include an
investigation into physical mistreatment of older people who were mentally frail by
staff at Beech House in London, UK, over a 3-year period (1993–1996) (Trust
1999), and more recently Orchid view care home, where neglect was found to have
contributed to deaths of ve residents (Commission 2014). Common factors in
these and other serious case reviews included: a poor and institutionalized environ-
ment; inadequate stafng levels, high use of bank and agency staff; little staff devel-
opment and poor supervision; a lack of knowledge of incident reporting; closed
inward looking culture; weak management, low staff morale and lack of involve-
ment by relatives in care delivery, decision making and evaluation of service.
10.5 Interventions toReduce or Prevent Elder Abuse
Measuring abuse is necessary to develop interventions to reduce it, but there are
ethical dilemmas regarding how to manage concerning cases detected, or in decid-
ing to measure abuse anonymously so they cannot be managed. Most abusive
behaviour happens when quality of care is poor and carers, family, or professionals
do not have other strategies to manage difcult situations. Abuse is sometimes, but
rarely, sadistic. Encouragement of naming and reporting of abusive behavior is an
important rst step to reducing it. Management of the most serious cases of abuse,
including nancial abuse, physical violence, and occasionally murder, involves
criminal justice systems. National legal frameworks for managing abuse vary; in
California, medical professionals have been criminally charged and sentenced under
elder abuse laws for the illegal chemical restraint (medication for the sole purpose
of sedation) of patients (Livingston etal. 2017). We discuss below the limited evi-
dence base regarding how to reduce and prevent abusive behaviours towards people
living with dementia.
10.6 Preventing Abusive Behavior by Family Carers
A recent Cochrane review reported only one study that sought to reduce the occur-
rence of elder abuse in people living with dementia by addressing underlying risk
factors (Baker etal. 2016). This study found no evidence that the START (STrAtegies
for RelaTives) intervention, a manualized coping-based intervention which reduced
carer anxiety and depression, also reduced their reported abusive behavior. For ethi-
cal reasons, the study team frequently intervened to manage concerning abuse
reported in both groups, which may have masked an intervention effect. The
researchers found that abusive behaviors decreased in carers in the intervention and
control groups (Livingston etal. 2014; Cooper etal. 2015).
C. Cooper and G. Livingston
143
10.7 Preventing Abusive Behavior by Professional Carers
10.7.1 Increasing Knowledge, Awareness andReporting
In a systematic review, four of the ve studies that sought to reduce psychological
abuse by paid carers through education, communication training and support did so
signicantly, although only one was a randomized controlled trial and was thought
to be potentially contaminated. The review also identied two studies that had
sought to increase the frequency of abuse reporting or assessment. The rst found a
non-signicant increase in elder abuse reports in Japan after introduction of the
elder abuse prevention and caregiver support law; the second that an educational
intervention did not signicantly increase the proportion of clinicians routinely
assessing for abuse, although abuse status was more frequently charted (Ayalon
etal. 2016). In two UK studies involving psychiatry trainee doctors and multidisci-
plinary mental health care teams, brief, knowledge-based interventions increased
understandings about how to detect and manage abuse and there was an indication
this may have led to an increase in reported abuse (Cooper etal. 2012, Richardson
etal. 2002).
10.7.2 Reducing Physically Restraint
Several interventions trialed in research studies have sought to reduce use of physi-
cal restraints, such as bilateral bed rails, belts, and xed tables in a chair, in institu-
tional settings (Ayalon et al. 2016; Cooper and Livingston 2016). In most
jurisdictions, use of restraint is subject to legal safeguards. While any unnecessary
restraint is considered unacceptable, opinions about the relative harms of using
sedating psychotropic medication or physical restraint to manage behavioral distur-
bance that may otherwise cause harm vary between countries. Some describe the
use of psychotropic drugs in this context as chemical restraint, although this medi-
cation may be given to treat an underlying problem rather than to prevent the recipi-
ent’s movement. In the UK, physical restraint is only legally acceptable if the person
is likely to suffer harm unless proportionate restraint is used, and it is the minimum
amount of force for the shortest time possible (Mental Capacity Act 2005). No UK
research studies have included physical restraint as an outcome, probably because
no level of ongoing physical restraint would be considered acceptable. By contrast
there has traditionally been a preference for use of seclusion and physical restraint
over chemical restraint in the Netherlands, although this is changing (Steinert etal.
2014). Interventions to educate front line staff about harms caused by physical
restraint, and teach alternative, person-centred care strategies successfully reduced
physical restraint (Ayalon etal. 2016). Similar programs have been successful in
reducing antipsychotic use in care homes (Fossey etal. 2006).
10 Elder Abuse andDementia
144
10.8 Conclusion
People living with dementia are at increased risk of elder abuse. Family carers of
people with dementia often report acting abusively when asked. Those caring for
people exhibiting challenging and aggressive behaviors, who are caring for more
hours and are experiencing high carer burden are most likely to act abusively.
Abusive and neglectful behaviors have been reported in most care homes where
research studies have studied this through anonymous reporting, suggesting that
widespread introduction of anonymous reporting should be considered in care
homes. In professional carers, experiencing burnout appears to be an important pre-
dictor of acting abusively.
While the high prevalence of abuse in people with dementia indicates a pressing
need for strategies to reduce and prevent it, the only elder abuse interventions for
which there is good evidence of efcacy in people with dementia target use of phys-
ical restraint, and were developed in countries where restraint is acceptable in some
circumstances (Ayalon 2015). There are no interventions known to effectively
reduce other abusive behaviors, partially due to difculties measuring outcomes that
paid carers are unwilling and residents with dementia unable or unwilling to report.
Future interventions to reduce abusive behavior by professional carers should focus
on reducing staff burnout and depersonalization; introducing true person-centred
care by encouraging staff to explore residents’ personal histories, current and past
interests and build pleasant interactions into care, as well as reducing objectication
of residents would from our ndings, be rational strategies. The current limited
evidence base regarding how to reduce family carer-perpetrated abuse towards peo-
ple living with dementia would suggest that development and trials of a coping-
strategy- based intervention that specically targeted abusive behavior would be a
rational next step.
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with Alzheimer's disease. Journal of Aging Research, 2013, 920324.
Wang, J.J. (2005). Psychological abuse behavior exhibited by caregivers in the care of the elderly
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10 Elder Abuse andDementia
149© Springer Nature Switzerland AG 2020
A. Phelan (ed.), Advances in Elder Abuse Research, International Perspectives
on Aging 24, https://doi.org/10.1007/978-3-030-25093-5_11
Chapter 11
Elder Abuse intheLGBT Community
GloriaM.Gutman, ClaireRobson, andJenniferMarchbank
11.1 Introduction
Though a great deal has been written about elder abuse in the mainstream popula-
tion, most of it has failed to consider how, how often, and how differently, abuse
manifests in the Lesbian, Gay, Bisexual and Transgender (LGBT) community;
moreover, specic studies of elder abuse in the LGBT community are ‘practically
non-existent’ (Cook-Daniels 2017, p.543). These decits are all the more troubling
in light of Harrison and Rigg’s (2006) suggestion that elder abuse is one of the most
urgent issues to be addressed in the gay, lesbian, bisexual, transgender, and intersex
population. Clearly, we don’t know enough about LGBT elder abuse, but what we
do know is that any differences between LGBT elder abuse and elder abuse in the
general population have been predicated and generated (at least partially) by the
cultural context in which they have emerged. In this chapter, we discuss some of the
cultural differences and social perspectives that have inuenced the LGBT popula-
tion and consider how these might impact research, outreach, and initiatives
designed to address the issue.
As Westwood (2018, pp.3–4) has pointed out:
…the abuse of older people involves at its heart, an imbalance of power relations.
In the case of older LGBT victims of abuse, these power relationships are strongly
inuenced by both historic and current factors, which not only include cultural atti-
tudes, legislation, and social policies, but also how these have been perceived by
people who identify as LGBT.For these reasons, we will stress the value of involv-
ing LGBT participants in processes and discussions, not just as an afterthought, but
as an integral part of policy and program design. We illustrate and centre our argu-
ment in our experience of one co-led project: Raising Awareness of LGBT Elder
G. M. Gutman (*) · C. Robson · J. Marchbank
Simon Fraser University Vancouver, Vancouver, BC, Canada
e-mail: gutman@sfu.ca
150
Abuse conducted by the authors in Greater Vancouver, Canada, in 2015. This small
project, though modestly funded and brief in duration, generated considerable inter-
est from service providers and some positive changes in terms of awareness raising
and police, institutional, and home care provider training. We suggest that its suc-
cess is in large part due to its methodology, which was participatory, educational,
arts-engaged, digitally disseminated, and deeply networked in both the local com-
munity and across the province of British Columbia.
11.2 LGBT Terminology
In recent years, the acronym LGBTQ2SIA+ (Lesbian, Gay, Bisexual, Transgender,
Questioning/Queer, Two-Spirit, Intersex, Asexual) has emerged in North America.
Though this acronym is unwieldy and makes some people avoid discussion of
LGBT issues altogether because they are anxious that they will ‘use the wrong
words,’ it does acknowledge those not recognized in the phrase ‘gay and lesbian’–
the bisexual, transgender, Two-Spirit, intersex, and asexual people whose experi-
ences and issues have been ignored. In other regions, a commonly used acronym is
LGBTQ (Lesbian, Gay, Bisexual, Transgender and Queer). However, there are
many in the LGBT community, particularly in the older age group, who have dif-
cult memories of being assaulted with the call of ‘queer.’ In recognition of this, the
Q was dropped from this acronym for the purposes of the project discussed here.
There are also generational differences in the use of terminology, as many young
people condently reclaim ‘queer’ as an umbrella term to cover all persons identify-
ing as gender and/or sexually non-normative. In respect for the experiences of their
elders, the youth participants accepted the use of LGBT as the project’s acronym.
We must also point out here at the outset that even this comprehensive umbrella
acronym, and others like it, can serve to conate the experiences of a range of indi-
viduals with very different needs, backgrounds and circumstances. Much more
research is needed to understand and address these differences as they might impact
LGBT elder abuse. For instances, lesbians report greater nancial barriers to health-
care than gay men and are more likely to be partnered (Frederiksen-Goldsen etal.
2013). Bisexual women are at higher risk than lesbians for mental distress and poor
mental health (ibid). Further, ‘Ambiguity around inclusion of gender diverse people
can create further barriers and anxiety about accessing support’ (SafeLives 2018,
p.36) with trans women in particular concerned as to whether a women’s shelter
will accept her, or how she will be treated in one. Though these nuances lay beyond
the scope of our project (and this chapter), they require further research.
G. M. Gutman et al.
151
11.3 Elder Abuse: Denitions
The denition we use in this chapter (and our project) comes from the National
Initiative for Care of the Elderly (NICE),1 who dene it as the ‘[m]istreatment of
older adults…within a trust relationship’ (NICE 2015) including both actions and
behaviors or lack thereof. NICE list ve main forms: physical, emotional/psycho-
logical; nancial/material; sexual and neglect– all of which may be experienced by
both LGBT and non-LGBT victims. Westwood (2018) notes that the abuse of older
LGBT people can be seen as three sub-categories, (1) elder abuse of those who are
LGBT, (2) homo/transphobic abuse of LGBT persons who are also older and (3)
homo/transphobic abuse of people because they are both older and LGBT.
As several commentators have noted (Carbado etal. 2013; Hill Collins and Bilge
2016; Westwood 2018, p. 3), an intersectional approach is required in order to
understand ‘the way(s) in which, age(ing), gender, and sexuality interact to inform
the uneven experiences of older LGBT people.’ Further, as Bruckert and Law (2018,
p.5) note in relation to women ‘[i]ntersectionality allows for nuanced analyses and
sheds light on the complex interplay between social and structural factors that con-
dition… vulnerability to…violence.’ Our denition of LGBT elder abuse contains
all of the above and additionally follows feminist arguments that abuse is a product
of unequal power relations, not just between abuser and victim, but also in relation
to how they are both situated within ‘a host of interlocking, social, political, and
economic systems’ (Bruckert and Law 2018, p.7).
Much of the literature we draw upon in this chapter centres on the experiences of
LGBT people in North America, and our project was conducted in Canada, a coun-
try with rights and legal protections for LGBT people. Yet, as Morrissey and
Waymark (2017, p.139) note:
…the Universal Declaration of Human Rights makes it clear that all people have the same
basic rights. However, 73 countries and ve entities still criminalize members of our com-
munity and several routinely kill them for their orientation.
It must be emphasized that elder abuse of LGBT people in many parts of the world
includes national and institutional lack of protections.
11.4 Increased Risk Factors forLGBT Elders
As noted earlier, little is known about the prevalence of elder abuse in the LGBT
population, or indeed, the needs and issues of LGBT older adults generally, who
have been described as an invisible population (Brotman etal. 2003; de Vries and
Blando 2004). This invisibility is caused partly by heteronormativity, which both
overlooks LGBT identities and conates them within research on heterosexual
subjects (Institute of Medicine 2011) and also by a tendency towards concealment
1 NICE is a Canadian organisation with international partnerships in nine countries.
11 Elder Abuse intheLGBT Community
152
on the part of LGBT elders (Brotman etal. 2003; Kochman 1997; National Senior
Citizen’s Law Center 2011). Such silence is worrying, not only because it represents
an unfortunate gap in our knowledge and understandings, but also in that it is often
in such silences that oppression ourishes; as feminist commentator Solnit (2017
unpaginated) has put it: ‘silence is what allowed predators to rampage through the
decades unchecked.’ Historically, such silences have adversely affected LGBT peo-
ple, for instance during the AIDS epidemic in the 1980s, a time when it was not
unusual for health workers and other service providers to shun men who were sick
and dying (Johnson and Stryker 1993). Indeed, it was LGBT activists in NewYork
City who rst coined the cogent LGBT slogan ‘Silence = Death.’
Though the literature is largely silent on the subject of LGBT elder abuse, it does
suggest that LGBT elders are more at risk of being abused than their heterosexual
counterparts. For examples, LGBT individuals are less likely to be married, less
likely to have children or to nd their children supportive if they do have them
(Fredericksen-Goldsen etal. 2013). They are more likely to live alone, as well as to
feel lonely. The health impacts of exposure to discrimination are far-reaching and
include increased risk of mental illness (Brotman etal. 2003; Cabaj and Stein 1996).
LGBT people are more likely to be depressed, to be disabled (Frederiksen-Goldsen
etal. 2013), to have experienced various forms of trauma, and to have abused drugs
and alcohol (Choi and Meyer 2016). They are also at greater nancial risk, because
of discriminatory access to legal and social programs and lifetime disparity in earn-
ings (Choi and Meyer 2016). All these characteristics are known risk factors for
elder abuse (Pillemer etal. 2016).
11.5 LGBT Perspectives onHealth Care
Historically, LGBT elders have also experienced troubled relationships with the
health care system. Many have lived through extremely hostile times when their
sexual orientation was criminalized or seen as a mental illness to be ‘cured’ by
extreme therapies such as electric shock and aversion therapy. Homosexuality was
removed from the Diagnostic and Statistical Manual (DSM) in 1973, but as recently
as 2003, Brotman etal. (2003, p.192) found that gay and lesbian patients of all ages
still reported negative reactions from service providers, ranging from condescen-
sion, excessive curiosity and pity, through embarrassment, hostility, and outright
rejection. The Williams Institute Report on Aging (Choi and Meyer 2016) cites sev-
eral studies that suggest that fear of discrimination causes many older LGBT adults
to avoid or delay health care and to conceal their gender and sexual identity from
health providers. Such nondisclosure has been shown to be negatively associated
with the quality of care LGBT seniors receive and increases isolation (Stein and
Bonuck 2001).
When suspicion and fear exist around reporting even routine health problems,
LGBT elders are likely to feel that reporting abuse might expose both their abusers
and themselves to shame, embarrassment, and skepticism. Since they are less likely
G. M. Gutman et al.
153
to visit doctors, hospitals or health clinics, they are also less likely to be aware of
programs or information that might help them or be condent that these will be safe
or inclusive. Indeed, materials specic to LGBT elder abuse did not exist to our
knowledge (in Canada at least) until they were produced in our project.
11.6 Long-Term Care Facilities
Many older LGBT people fear entering long term care (LTC) facilities, as the
National Resource Center on LGBT Aging (2011, unpaginated) notes because they
fear encountering hostility and being pushed back ‘into the closet.’ In addition,
‘LGBT older adults who are cognitively or physically disabled are at a heightened
risk of relocation to LTC’ (Sussman etal. 2018, p.122) where LGBT appropriate
care may not be available. Sussman etal. (2018) surveyed Canadian care homes to
assess the level of LGBT training and services available and concluded that whereas
some were open to considering LGBT issues, the major step taken tended to com-
prise staff training with little or no changes to programming, for fear of negative
responses from hetero-normative residents and families. Brotman etal.’s (2003)
comprehensive report on the health and social service needs of LGBT seniors across
Canada painted a detailed and gloomy picture of continued discrimination and igno-
rance in LTC facilities, and the invisibility and silence of LGBT elders in this
context.
11.7 Shame, Self-Stigma, andLow Self-Esteem
LGBT elders have survived oppression, violence, and social exclusion. Their histo-
ries display tremendous strength and resilience in the face of these struggles, yet
there has also been a cost. Social marginalization, stigma, and oppression have led
to feelings of shame, self-stigma, and low self esteem for many LGBT elders (Yang
etal. 2018; Chamberland 1996; Kaufman and Raphael 1996) – feelings that can
only be compounded by the prospects of the increased dependence and physical
decline that routinely accompanies aging.
Since elder abuse is about the misuse of power and the abuse of trust, then it fol-
lows that its prime targets are those who might be easily convinced that they are
worthless, or ‘less-than.’ As Cooks-Daniel (2017, p.543) has pointed out
The history of social and interpersonal discrimination, violence, and trauma that LGBT
elders have experienced simply adds to the ways in which they can be threatened or manip-
ulated by abusers.
Cooks-Daniel goes on to list some LGBT-specic abuse tactics that may be
employed. These include threats to ‘out’ the LGBT elder (with implications for
access to grandchildren), suggestions that ‘this is what it means to be LGBT’ (for
11 Elder Abuse intheLGBT Community
154
instance in terms of abusive sexual behaviors), suggestions that ‘no one will believe
you’ or ‘they’ll think you’re crazy’ and inappropriate access to nances. Given that
same sex marriage has not always been available, assets may have been combined
without sufcient protective measures. From the victims’ perspective, internalized
homophobia, biphobia, or transphobia may also lead them to believe that this is ‘the
best I can expect,’ as earlier abuse make them more likely to believe that being
abused is ‘just the way things are.’ Fear of spending the rest of their lives alone may
inuence their decision to remain in an abusive relationship, and social isolation
may make them more dependent upon abusers. Gender issues inherent in the dis-
course about abuse can also be compounded in same sex relationships, as both male
and female victims are perceived to be less at risk because men are seen as able to
ght back, and women as unlikely to be dangerously aggressive.
11.8 LGBT Culture
Unfortunately, LGBT culture itself does not have a strong history of supporting
elders, since it tends to be both youth oriented and at times ageist. In recent years,
LGBT activism in Canada and the United States (US) has tended to centre upon the
achievement of gay marriage. Harrison and Riggs (2006) note a signicant lack of
awareness and discussion of aging in LGBT public forums or media.
11.9 Raising Awareness andAddressing Elder Abuse
intheLGBT Community
11.9.1 Project Description
In 2015, two community activist groups– Youth for A Change and Quirk-e– the
Queer Imaging and Riting Kollective for Elders, with funding provided by the
British Columbia Council to Reduce Elder Abuse, worked collaboratively on an
intergenerational, community-based participatory digital arts project, Raising
Awareness and Addressing Elder Abuse in the LGBT Community (Robson etal.
2018). The objective of the initial phase of the project was to create educational
materials that would raise awareness of elder abuse in the LGBT community, in the
process building knowledge of elder abuse among the participants (a topic previ-
ously unfamiliar to both the youth and the elders), build social capital, as well as art
skills. The project was conducted in Greater Vancouver, British Columbia, Canada,
where both groups are based. Chapter author Jen Marchbank and her wife Sylvie
Traphan facilitate the youth group and chapter author Claire Robson facilitated the
elder creative writer/arts activist group at the time the project was conducted (2015–
2016). Chapter author Gloria Gutman led the project, and the arts component was
G. M. Gutman et al.
155
led by Kelsey Blair, a doctoral student in the English Department at Simon Fraser
University and co-facilitator (with Robson) of Quirk-e.
In total, ve posters and three videos were produced following which teams
(comprising one of the three chapter authors, one youth, and one Quirk-e elder)
premiered them at Town Hall meetings held in each of British Columbia’s ve
regional health authorities. Advance invitations were sent to local LGBT organiza-
tions, health agencies, local seniors’ organizations, individuals within the regional
health authorities who were designated to respond to elder abuse and those focused
on sexual health. Typically, we found that service providers in these latter two
groups did not know or communicate with each other even though they worked for
the same organization.
The goals of the Town Halls were to (1) raise awareness of elder abuse within the
LGBT community; (2) raise awareness among those who provide elder abuse ser-
vices of the additional risks of abuse that may accrue to LGBT older adults; and (3)
familiarize both of these groups and current/potential victims with local services
they might access in addressing the various types of elder abuse.
It should be noted here that both Jen Marchbank and Claire Robson are well
known as LGBT activists with extensive networks in the LGBT community, while
Gloria Gutman, a gerontologist, elder abuse researcher, and seniors’ advocate, has
strong connections with the seniors’ community and agencies who provide health
and social care, legal services, housing etc. targeted to them. Their extensive net-
works were fully exploited in promoting the Town Halls.
11.10 Project Outcomes
Three videos (available at www.sfu.ca/lgbteol) were made depicting the following
scenarios: emotional/psychological and physical abuse (a lesbian couple, one of
whom feels that her partner’s butch appearance will out her and thus threaten her
access to her grandchildren, so becomes physically abusive), nancial abuse (a gay
male couple where the younger partner makes unauthorized withdrawals from the
older partner’s bank account), and institutional neglect (a female to male trans indi-
vidual being upbraided for requesting a pap smear). The ve posters/fact sheets
(shown as Figs.11.1, 11.2, 11.3, 11.4, 11.5, and 11.6 below) dene the ve main
types of abuse and list local services addressing them. All these materials were
taken into six British Columbia communities (Vancouver, Surrey, Victoria, Kelowna,
Nelson, and Prince George) via the Town Hall meetings (attendance=21–57 per
meeting). Two further community dialogues were held, in partnership with local
community organizations, with service providers working with ethnic Chinese and
ethnic South Asian seniors, the two largest ethnic minorities in the province.
At the time of writing, the project has gone far beyond the original dissemination
plan. For example, the project drew the attention of the LGBT Advisory Committee
of the City of Vancouver, and at their request, the posters were displayed in all 24
community centres in the city. The materials have been presented at Social Planning
11 Elder Abuse intheLGBT Community
156
Fig. 11.1 Poster 1
Fig. 11.2 Poster 2
G. M. Gutman et al.
157
Fig. 11.3 Poster 3
Fig. 11.4 Poster 4
11 Elder Abuse intheLGBT Community
158
Committee meetings of two city councils in British Columbia. They have been inte-
grated into the Sociology and Gender Studies curricula in two BC institutions of
higher learning and into the care aide training program of a third British Columbian
university. They have been used by other provinces (e.g. Nova Scotia Environment),
integrated into the medical curriculum in an English university and presented at a
Violence Against Women network meeting in south Scotland as well as local,
national and international Gerontology, Education, and Action Research confer-
ences. All 2500 posters have been distributed and over 1400 people have down-
loaded the videos.
11.11 Discussion
11.11.1 Nothing About Us Without Us
Similar to the Irish organization, Sage Advocacy (see chapter by Taylor), disability
groups have used the phrase ‘Nothing About Us Without Us’ in order to emphasize
the importance of being considered full and direct participants in the inception,
discussion, development and implementation of policies that affect them. We
believe that one of the most signicant strengths of our project was the inclusion
and direct involvement of LGBT youth and elders, not only in designing, but also in
Fig. 11.5 Poster 5
G. M. Gutman et al.
159
disseminating the materials and in speaking directly to service providers, academ-
ics, and seniors’ and LGBT organizations.
Older people, as a group, are often regarded as a burden, with mainstream media
portraying them as ‘a grey tsunami’ demanding rather than providing services and
thus placing a burden on taxpayers (Cruikshank 2013; Bingham 2013). As far as
LGBT elders are concerned, these perceptions of frailty and helplessness are
Fig. 11.6 The reverse side of all ve posters
11 Elder Abuse intheLGBT Community
160
compounded by the greater likelihood of experiencing disability, depression, mental
illness, and social isolation. Though the health care system has moved beyond the
outright criminalization and medicalization of LGBT individuals, narratives of
helplessness and victimhood continue to dog both queer elders and queer youth
(Saewyc 2007; Ryan etal. 2009). Though it is important to recognize the challenges
faced by LGBT youth and elders, it is vital that service providers understand the
importance of supporting their resilience, condence, and sense of agency. Research
has shown that an overemphasis on frailty by health care professionals can lead
them to ignore the importance of developing resilience as a key strategy for success-
ful aging (Resnick etal. 2011; Kuchel 2018).
It is difcult to overestimate the importance of emphasizing emotional and psy-
chological resilience in the context of LGBT elder abuse, where continued invisibil-
ity and self-stigma are key factors. The health care providers who attended our
presentations were able to put a face to the statistics and to regard our participants
as experts and contributors, rather than victims and consumers. Changing the narra-
tive contributed positively not only to the ways others viewed them, but the ways in
which they viewed themselves, as they were positioned as leaders, advocates,
spokespeople, and even experts. Our participants were proud of both the materials
they produced and their ability to speak in public. Typically, those who attended
their presentations reported that they were impressed with participants’ in-depth
knowledge of the issues, and their ability to answer follow-up questions or position
the specics of the discussion in broad cultural terms.
11.12 Acknowledging Intersectionality
As the youth and elders considered the design of the ve posters and the three vid-
eos, they were faced with a critical artistic challenge– how to represent the com-
plexity of LGBT elder abuse through a few simple images and brief text on the
posters, and through only three scenarios on the videos. Both their discussions and
their consequent choices acknowledged and forefronted the intersectionality of
LGBT elders in terms of race, gender, sexual orientation, occupation, and interests.
The images and texts on the posters show that abused LGBT elders are not just old
and victimized, but also grandmothers, hobbyists, and exercise enthusiasts (among
other identications), and that abuse happens to people of all races and sexual ori-
entations. Since there is considerable silence about lesbian and transgender experi-
ences generally, the youth and elders decided to highlight these in two of the three
videos. They also wanted to represent and acknowledge systemic oppression, par-
ticularly abusive situations in residential care (the subject of the third video).
G. M. Gutman et al.
161
11.13 Choices Around Dissemination
Much has been written about the informal networks and systems of support forged
by LGBT people (Hyun-Jun etal. 2017), and we believe that it is essential to under-
stand and utilize these in outreach. Though elder abuse materials are generally dis-
tributed in hospitals and clinics, we chose a different model, given the general
mistrust of health care services by LGBT people. In addition to the screenings that
occurred at Town Hall meetings, all the materials produced were and still are avail-
able digitally and free of charge, and much of our publicity was and is conducted
through social media platforms familiar to LGBT and seniors’ populations in British
Columbia.
Another key element of our project was to involve, from the initial proposal
stage, community partners (listed below), including LGBT and LGBT friendly
organizations:
• QMUNITY (a nonprot LGBTQ/2S organization for British Columbia)
• West End Seniors’ Network
• Haro Park Centre (a seniors’ housing and LTC facility in the heart of one of
Vancouver’s LGBT communities)
• Alzheimer’s Society of British Columbia
• The Health Initiative for Men
• Gay and Grey Men’s Group
• Quirk-e
• Youth for A Change
• Britannia Community Services Centre (located in Grandview Woodlands,
another of Vancouver’s LGBT communities)
• British Columbia’s ve health authorities (Fraser health, Interior Health,
Northern Health, Vancouver Coastal Health, and Island Health)
It should also be noted that we built upon the networks of Marchbank and Robson
(as noted earlier, well-known LGBT activists), and that of the third author, Gutman,
who had just completed a participatory community project on end-of-life care in the
LGBT community and was thus regarded as an ally (de Vries etal. 2019). We strove
as far as possible to disseminate the materials in community spaces. As far as we
could, we publicized the Town Hall meetings in ways that attracted not only service
providers, but also local LGBT organizations, and members of the community.
11.14 Bridging Silos
Thus far in our chapter, we have not addressed the intergenerational aspect of the
project, but we see this as highly important. One of the challenges facing health and
other service providers is the existence of silos in and among various institutions
(Seddon etal. 2013, p.86). These silos include the separation of LGBT youth and
11 Elder Abuse intheLGBT Community
162
seniors; of academics and practitioners; and of the divisions of the health authorities
that provide elder abuse services and those that are responsible for promoting sexual
health. Services to seniors, especially seniors from marginalized groups such as the
LGBT community and/or ethnic minority groups, must be intersectional and cultur-
ally appropriate. It cannot be assumed that services and supports that are experi-
enced positively by hetero-normative seniors are necessarily appropriate for LGBT
seniors.
Similar silos exist in the LGBT community itself, most notably across the lines
of age and gender. This project demonstrated that the silos that characterize services
to abused older adults, the LGBT community, and the general population of older
adults can be bridged by projects that involve the local community as they reach
across generations and disciplines and generate academy/community collabora-
tions. It also served to educate younger LGBT activists about the issue of elder
abuse in their community, thus constructing awareness for the community’s future
leaders and advocates. The ultimate aim of this project and of this chapter is to edu-
cate. We set out to educate service providers in health and social care in British
Columbia, yet we believe that the project went far beyond these goals. The youth
and elders developed skills in script writing, editing, acting, design, marketing, and
directing. They learned about elder abuse, and educated members of the Town Hall
meetings, building upon their own lived experience as LGBT persons, all whilst
developing materials for service providers to incorporate into staff training
activities.
11.15 Conclusion
Over 15years ago, Brotman and her colleagues stated an urgent need to create more
equitable, open, and supportive environments for LGBT elders (Brotman et al.
2003, p.199) including the recognition of homophobia as a form of elder abuse for
this community. At the time of writing, we do not believe that their call has been
adequately answered. More research is needed to determine the extent of LGBT
elder abuse in its various forms, by individual partners, caregivers, and family mem-
bers, and by institutions. Much more action is required to address it through appro-
priate initiatives, such as targeted training for health and social service providers
and police, and the adaptation of policies and procedures to make elder abuse ser-
vices more LGBT friendly. It is essential that LGBT individuals, communities, and
organizations be regarded as essential partners in processes of institutional change,
and that their voices are heard, recognized and celebrated.
G. M. Gutman et al.
163
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165© Springer Nature Switzerland AG 2020
A. Phelan (ed.), Advances in Elder Abuse Research, International Perspectives
on Aging 24, https://doi.org/10.1007/978-3-030-25093-5_12
Chapter 12
Gender Issues inElder Abuse
BridgetPenhale
12.1 Introduction andBackground– Key Issues
Over the last decade, the issue of elder abuse has gained importance at international
and European Union (EU) levels. The World Health Organisation (WHO) and the
International Network of the Prevention of Elder abuse (INPEA) have recognised
the abuse of older people as a signicant global problem, and this has been accepted
in a more global sense. In the last three decades, there has been increasing recogni-
tion in the United Kingdom (UK) of the abuse and neglect of older adults as a
social problem in need of attention, although in some other countries such recogni-
tion and resulting attention to the issue has been rather more recent. Elder abuse is
a human rights violation resulting in suffering, decreased quality of life and even in
some situations hastening mortality. Moreover, it is an infringement of Article 25
of the EU Charter of Fundamental Rights, which recognises and respects the rights
of older people to lead lives of dignity and independence, and to participate in
social and cultural life. The majority of older people are female, and more older
women experience abuse than older men (even when controlling for the differences
in proportion of the population). It is therefore timely to consider violence and
abuse of older women as a topic in its own right. This chapter will explore a num-
ber of these issues.
Elder abuse and neglect is a complex and sensitive topic to fully and properly
investigate. This situation was also found, initially, with child abuse and domestic
violence against younger women. Establishing a sound theoretical base for elder
mistreatment (a term used to denote elder abuse and neglect) has presented chal-
lenges, in part due to a lack of agreement about the need for a standard denition,
but also because of problems in researching the topic and developing appropriate
methods to do so (cf. Ogg and Munn-Giddings 1993; Penhale 1999a). However,
B. Penhale (*)
School of Health Sciences, University of East Anglia, Norwich, UK
e-mail: B.Penhale@uea.ac.uk
166
despite these difculties, a number of denitions of elder abuse have emerged and
one of the denitions that is most commonly referred to is the one used by WHO
and the International Network for the Prevention of Elder Abuse (INPEA), follow-
ing the denition developed by the organization Action on Elder Abuse (AEA
1995). Included within most denitions and associated typologies are the following
types of abuse: physical, sexual, psychological, nancial (or material abuse) and
neglect. To this list, additional aspects of abuse have been added such as institu-
tional abuse, violations of rights, and social abuse; these have also been incorpo-
rated within a number of denitions and understandings of abuse. Lists of indicators
of abuse have also been developed over time, although it is problematic to diagnose
mistreatment (O’Keeffe etal. 2007) solely through the use of indicators. In more
general terms, debate still exists about denitions, indicators of mistreatment and
different aspects of abuse and neglect.
It is also clear that there is still a general lack of awareness of abuse in many
countries and this can lead to difculties in detection and identication of abuse and
neglect by practitioners as well as the wider public and older people themselves.
Indeed, reports of which type of abuse is most common varies between surveys,
with no absolutely consistent pattern of ndings and differences occurring between
studies at the national level. Early American research indicated that most instances
of elder abuse appear recurrent and part of a pattern, rather than a single incident
(O’Malley etal. 1981).
When considering the term vulnerability and it’s usage, there is a need to recog-
nize that there are issues that relate to visibility and invisibility about what is recog-
nized as mistreatment or not, as well as such aspects as marginalization and exclusion
of individuals who may be considered vulnerable, or at risk of mistreatment and/or
harm. Current understandings strongly suggest that vulnerability seems to be largely
situational; this means it is not only the characteristics of the person that results in
assignment of the status ‘vulnerable’ but instead, it is the interaction with and inter-
play between other situational and circumstantial factors that lead to the occurrence
a vulnerable state for the individual (Penhale and Parker 2008). Vulnerability is a
social construction and a social model, and, as outlined above would seem most
appropriate in relation to its conceptualization within understandings of abuse.
Moreover, those individuals who are often deemed to be most at risk are the people
who are acknowledged to be from ‘hard to reach’ or ‘seldom heard’ groups and who
may experience life on the very margins of society. This is likely to have adverse
effects on individuals’ health and well-being, not just in relation to physical health
but also states of mental well-being and some of these impacts may be very signi-
cant. It is apparent too that some older individuals who have impairments, either due
to a physical or cognitive related illness or disability- or perhaps also more complex
conditions, that may combine both aspects, may also be ‘hard to reach’. This is
because the level of needs of such people could mean that these are not fully
addressed by the service structures that exist. Such aspects as these might be par-
ticularly relevant in relation to individuals’ experiences of abuse and violence, as the
service structure and provision in a locality (or even nationally) may not serve these
types of intersecting interests in a satisfactory or even relevant way. In addition, the
B. Penhale
167
nature of public policy, provision of services and the dynamic and evolving quality
of relationships between the individual and the state (perhaps in this context in par-
ticular, the welfare state) requires further exploration in relation to mistreatment,
whether this is violence, abuse, neglect or exploitation (mistreatment is the term
used to encompass these aspects, as suggested by O’Keeffe etal. 2007).
Additionally, a further set of issues are connected to family relations and familial
matters. Throughout the last century, perhaps particularly in western and more
industrialized countries, a signicant number of changes occurred to family struc-
tures. Family types and patterns both altered and developed as a result of such
changes; an example of this can be seen in the rise in the extent of lone parenting
and increases in the number of re-constituted families following divorce and separa-
tion. Furthermore, increases in multi-generational families, some of whom share
accommodation and family life have occurred in many countries, in part due to the
demographic changes that have occurred globally with aging populations across
most countries and the rising number of people living into late old age (Antonucci
2007). Substantial effects have also been found relating to socio-demographic fac-
tors such as gender, education, income and marital status. These and other factors
have had considerable effects on the dynamics and patterns of familial relationships
in the twenty-rst century and also on the nature of caregiving in later life, about
which we still know too little.
The issue of elder abuse was acknowledged as a social problem several decades
after the recognition of child abuse and domestic violence as signicant issues for
society to deal with. In addition, there is a need here to acknowledge the importance
of professional recognition of the issue as a problem that required attention from
health and human services professionals, if not society more broadly. The situation
in relation to elder abuse is similar to the situation of child abuse/protection, when
in the late 1960s and early 1970s (in the UK) it was medical clinicians that rst
raised concerns about this form of abuse. However, concerning the area of domestic
violence against younger adult women, it was activists in the second wave of the
feminist movement (in the 1970s) who initially identied violence and abuse
directed towards women and drew attention to the need to develop responses to the
problem. This latter identication incorporated more of a ‘grass-roots’ and political
approach by feminists to the perceived problem, and one that directed broader soci-
etal attention towards this issue. Yet in relation to elder abuse and neglect, it was not
until the 1980s within a European context, that professionals began to draw atten-
tion to the issue of mistreatment and as noted, the responses were similar to those
that had developed earlier with children and young people. This issue of identica-
tion is relevant, as it has had an impact on what has happened in the development of
strategies concerning the prevention of abuse, protection of and provision for those
who are abused, and it also informs the lack of awareness by the wider public of the
issue (Penhale 2008). Additionally, it is likely that the identication and recognition
of elder abuse as a social problem may also have been affected by such initial iden-
tication and orientation.
From what we know to date, elder abuse and neglect appears to be a complex and
multi-factorial phenomenon. Yet, there are a number of problems in interpretations
12 Gender Issues inElder Abuse
168
of the evidence that exists. Several of the causal factors that have been advocated as
pertinent to elder abuse seem to focus more on micro, individual level factors. As a
result, potential macro, structural level factors are not wholly considered and there
often seems to be an associated attribution of pathology to older people, perhaps
especially individuals who have some form of disability, of whatever type. One
instance of this can be seen when an older person who is dependent on others for
needs relating to care and support is perceived as a source of stress and as a result is
viewed as responsible (at least to some extent) for abuse that arises within such situ-
ations. Perceptions of pathology such as these may suggest conrmation of existing
societal views and opinions of older people as dependent and powerless, which is
not helpful. In spite of sustained attempts to disseminate the social model of dis-
ability across societies, the example provided in relation to older people is very
similar to existing and still relatively prevalent societal perceptions of disabled peo-
ple as both dependent and helpless and consequently not able to either care for
themselves or live independently.
In general, older women are disproportionately affected by disability, poverty
and violence. Through the course of a lifetime, gender-based differences in employ-
ment, healthcare and education negatively inuence the physical and mental well-
being of women, with a cumulative effect in later life (World Health Organization
2015). Therefore, people who are both older and disabled might be more likely to
be considered as helpless and dependent and as a result to experience an increase in
vulnerability, due to this intersectionality between age and disability (Crockett etal.
2018). Such situational vulnerability, discussed above, which is made more com-
plex by intersectional issues like this, also includes exposure to mistreatment so that
older disabled individuals (and in particular women) are more likely to experience
violence in their daily lives. On the other hand, this type of positioning of older and
disabled people as dependent and powerless also fails to take account of the poten-
tial role of a number of other aspects, one example being the potential of neighbor-
hood and community to provide support (Buffel etal. 2009) to act as protective
factors against the development of situations that are abusive in nature.
12.2 Violence AgainstWomen: IncludingGender inElder
Abuse
Since the 1970s, we have seen the development of an acknowledgement that vio-
lence against women is a human rights and public health issue, with signicant and
enduring impacts on women’s life and health. In recent years, an increasing number
of studies have started to explore women’s experience of violence at different ages–
including the extent to which older women experience partner abuse.
Around 500,000 older people are believed to be abused at any one time in the UK,
with most victims of elder abuse being older women with a chronic illness or dis-
ability, according to statistics provided by the government information service. The
B. Penhale
169
recent Women’s Aid and Counting Dead Women project annual Femicide Report
shows that of those women killed, most of the women aged over 60years were killed
by a male family member, either a spouse or a son/grandson (Long etal. 2018).
Older women experiencing domestic and/or sexual violence may be afraid to
seek help or may not know how to access support and they are less likely to report
crimes or to make use of any services that might be available (Beaulaurier etal.
2008; Blood 2004; Safe Lives 2016).
Older women face particular obstacles to disclosure and help-seeking, which
have not been adequately acknowledged and are not sufciently understood or pro-
vided for. Against the backdrop of the global ageing population, it is fundamental
that health and social care professionals are able to both identify gender-based vio-
lence and abuse and understand the particular experiences, needs and rights of older
women. Gender based violence and abuse amongst older women can be overlooked
by health and social care providers, with their (understandable) perspectives on and
orientation towards health, care and welfare. It is apparent that when women become
‘older’ their gender seems to be forgotten or becomes hidden, or invisible. This
means that older women’s experiences of gender-based violence may often not be
either recognized or responded to in an appropriate and timely way. Thus, it is likely
that professional practice that is both age-sensitive and gender-responsive is needed
(Crockett etal. 2018).
Whilst violence against older women is often only considered in the context of
care and dependency (Bows 2019), several reviews have shown that violence against
older women is mainly perpetrated by intimate partners (for example, see Penhale
2003). Although a number of studies suggest that the prevalence of intimate partner
violence (IPV) is lower among older women when compared to rates of IPV towards
younger women (Burazeri etal. 2005; Helweg-Larsen etal. 2011), we need to be
cautious about comparisons of this kind, as these studies are mainly small scale and
with differential coverage in terms of research designs, measurements of violence
and age categories. Furthermore, apart from the 1992 National Violence against
Women Survey (Greenfeld etal. 1998), and National Crime Victimization surveys
in the United States (US) held in 1993 and 1999 (Rennison 2001), few studies con-
sist of data that is nationally representative. Yon and colleagues undertook a system-
atic review and meta-analysis of self-reported elder abuse by older women living in
the community and found that despite signicant variations in prevalence, and lack
of robust evidence, particularly in low and middle-income countries, about 1in 6
women experience abuse across the world (Yon etal. 2019). In addition, intimate
partner violence towards older women is often viewed in the context of their per-
ceived greater vulnerability and dependency on their partner (but see above for
comments on vulnerability). However, this has been rebutted by several small-scale
studies that show quite similar factors associated with intimate partner violence
amongst older and younger women (cf. Phillips 2000).
Numerous studies have shown that intimate partner violence has signicant
adverse physical and psychological health outcomes, especially among older
women (Fisher and Regan 2006; Fisher etal. 2011; Mouton 2003), regardless of
whether such violence is a continuation of violence that has occurred throughout the
12 Gender Issues inElder Abuse
170
history of the relationship, or whether it has commenced ‘de novo’ in older age.
Addressing intimate partner violence among older women is therefore not only
important in itself, but there are also some evident implications for their health,
well-being and physical functioning (Stockl and Penhale 2015). In order to develop
appropriate and effective interventions relating to older women who experience inti-
mate partner violence, more needs to be known about its prevalence and the factors
associated with increased risk.
In Europe, several representative studies have investigated the prevalence of inti-
mate partner violence and the factors associated with it at national levels (Hagemann-
White 2001). Unfortunately, only a few of these surveys included women above the
age of 50years (Burazeri etal. 2005; Helweg-Larsen etal. 2011; Papadakaki etal.
2009; Zorrilla etal. 2010). There is large variation between these studies relating to
the age categories used for women above reproductive age and sometimes these are
not provided at all. Although the overall ndings of these studies was that the life-
time prevalence of intimate partner violence reduced with increasing age, none of
the studies specically investigated what results in older women being at increased
risk of intimate partner violence, with an inherent implicit assumption that factors
associated with this would be similar (if not exactly the same) across different age
cohorts. In addition, two more recent prevalence studies of elder abuse in Europe
did not fully consider intimate partner violence in later life, but rather focused on
the wider context of elder abuse and abuse against older women (Soares etal. 2010;
Luoma etal. 2011). Another European study on intimate partner violence against
older women did not explore either prevalence or factors associated with it (Nagele
etal. 2011) but rather considered help-seeking and perceptions of responses. For
these reasons, a key remaining gap is representative, population-based data to
enable comparisons of prevalence rates and risk factors associated with intimate
partner violence across generations, or with a specic focus on mid- and later life
(Rennison and Rand 2003).
Throughout the literature on elder abuse and the evidence base from research that
has developed in the past two decades, it is generally understood that males are
more likely to abuse than women and that women are more likely to be abused than
men within situations of elder abuse (Brossoie and Roberto 2015). This may lead to
some suggestion that labels men as abusers/perpetrators and women as abused/vic-
tims. When that consideration is simply on a numerical basis, this appears to be a
reasonably clear nding, but there is a need for abuse to be understood from a much
broader perspective. Such a perception necessitates an understanding of the societal
context(s) of abuse. This would also require, for instance, an appreciation of the
possibility that some women act abusively, and that some men experience abuse
(Soares etal. 2010; Teaster etal. 2007). Furthermore, it is possible that the propor-
tion of older men who experience and report some form of elder abuse is perhaps
higher than the proportion of younger adult men who report abuse in relation to
what might be considered to be situations of domestic violence (Soares etal. 2010).
Whilst it is apparent that both older men and women experience abuse, the
majority of victims of elder abuse are female, even when this is corrected for by the
fact that there are more older women in the population (Brossoie and Roberto 2015).
B. Penhale
171
Further, while there is still uncertainty regarding the rates of elder abuse either as an
overall gure or with regard to the various sub-types, due to a lack of international
comparative prevalence data, it can be stated with some certainty that abuse within
the domestic setting occurs across all ethnic and socio-economic groups and in both
urban and rural areas (Acierno etal. 2010). However, it is generally recognized that
in relation to sexual abuse of elders, the majority of those who experience such
abuse are women (Bows 2018; Teaster and Roberto 2004). Through the life-course,
women are more likely than men to experience violence from an intimate partner, to
be a victim of sexual assault, to live in poverty, develop a disability or to have
reduced access to education and healthcare. As they age, the enduring and cumula-
tive effects of these differences increase (Crockett etal. 2018; Mears 2015). Older
women of color, which includes individuals from immigrant communities, older
women with disabilities, and older lesbian, bisexual and trans-women, may in addi-
tion face greater, exceptional difculties (Mears 2015). A composite of barriers due
to attitudes, policies or resources may lead to exacerbation of situational vulnerabil-
ity for older women, in an intersectional and stigmatizing way (Choi etal. 2017).
Those who are involved in mistreatment may be male, female; partners, adult
children or other relatives. As found with other forms of familial violence, the
majority of abusers are men. If the probability of abuse is corrected for by the
amount of time that the perpetrator spends with the victim, men are much more
likely to be involved in abusive acts, particularly those which are physically violent
(Finkelhor 1983). Traditionally, elder abuse that happens in domestic settings has
been seen as a problem occurring between a female abuser, often a caregiver (per-
haps a daughter), and older parents. A number of early studies of elder abuse indi-
cated that abusers were more likely to be female, usually relatives (Eastman 1984).
Nevertheless, following further analyses of such data, including attention given to a
distinction between physical abuse and neglectful acts (and/or omissions), it has
been established that men are more likely to be involved in physical violence and
women in neglectful acts (Miller and Dodder 1989; Sengstock 1991). Since catego-
ries of neglect were very high in the studies that were reviewed this largely explained
why it had appeared that the majority of abusers were women.
Research concerning the characteristics of abusers and abused has indicated
rather contradictory results regarding gender. Adult Protective Service gures reveal
most victims are female (68%) (Tatara 1993) and in the UK prevalence study, older
women reported mistreatment at more than double the rate of older men (3.8% vs
1.1%) (O’Keeffe etal. 2007). The prevalence study undertaken in Ireland using a
comparable methodology established that older women (2.4%) were more likely to
report experiences of mistreatment in the previous year than older men (1.9%)
(Naughton etal. 2010). In the early prevalence survey, which used telephone calls
conducted from Boston in the US, the majority of victims were male (52%) (Pillemer
and Finkelhor 1988), whilst 65% of respondents to the calls and who undertook the
survey were female. The victimization rate for men at 5.1% was double that for
women (2.5%) and yet the older population was disproportionately female. It must
be taken into account, however, that women tend to sustain more serious abuse and
injuries than men (Swan etal. 2008). This might mean that older women are more
12 Gender Issues inElder Abuse
172
likely to need treatment for their injuries and other necessary forms of support and
that they may also be more likely to come to the attention of authorities and service
organizations.
It is possible, for instance, that women are more likely to report acts of mistreat-
ment than men or possibly, even, to seek assistance, although evidence about this is
limited. Also, as already stated, men are more likely to be physically violent and to
commit more serious violence than women. Thus, if much elder abuse is between
partners in later life, and the principal form of abuse for male abusers is physical
violence towards women, which may perhaps lead to a need for treatment, then it
could appear that more women are abused than men. Abusive behavior by women,
that is likely to be psychological or passively neglectful in type, may not result in
the need for any treatment for the male victim, or even any external reporting and so
it is possible that this might not come to the attention of professionals or authorities.
There may also be factors related to age cohorts involved here. In the UK prevalence
study (O’Keeffe etal. 2007), more older men in the oldest cohort (over 85years)
reported abuse than older women of comparable ages (who predominantly reported
neglect). The most frequent report of abuse by older men of this age grouping was
of nancial abuse. However, it is possible that the older male respondents perceived
it as easier, or less stigmatizing to report nancial abuse rather than, for example,
physical violence. As is found with younger women, sexual abuse in later life
appears to be highly gendered: those who are victims are female; those who abuse
are male (Bows 2019).
One of the acknowledged and established risk factors for elder abuse concerns
living with others and as men are more likely to live with someone else in old age,
this may well increase the risk to older men and possibly make abuse of older men
more likely. The early, seminal work of Kosberg (1998) and Pritchard (2001) in
considering the needs of older men who experience abuse is important to note here.
There is also some consistency with research into the characteristics of abusers:
someone who has lived with victim for a long time. The person involved as a perpe-
trator is most often a relative, usually adult children, spouses, grandchildren, sib-
lings then other relatives. The rst prevalence study, undertaken in the US by
Pillemer and Finkelhor (1988) found that abuse was mainly between partners in
later life and that abuse by non-family members was comparatively rare, a nding
that has been repeated in later prevalence studies (for example O’Keeffe etal. 2007;
Luoma etal. 2011). More recent studies have established that for certain forms of
mistreatment, such as nancial abuse, perpetration by other family members (who
were not partners) may be more likely (O’Keeffe etal. 2007; Naughton etal. 2010).
Kosberg (1998) suggested that in a number of situations, the motivation of
revenge or ‘pay back’ for previous abuses of power within relationships may oper-
ate. In this type of situation, a woman or children who experienced abuse from a
man at an earlier point in their family’s history may see the opportunity to act abu-
sively as a form of revenge on the man in later life, in particular if the man is in
need of care and support. Research in Sweden by Grafstrom etal. (1992) which
examined caregivers’ experiences found some evidence for this type of dynamic
taking place (see also Volmert and Lindland 2016). However, Jack (1994) suggests
B. Penhale
173
that female-to-female and female to male abuse need to be situated within the con-
text of exchange relationships within a dysfunctional and discriminatory society.
The potential effects of gender within abuse are inuenced by a number of fac-
tors. These include the type of abuse which occurs; the fact that there are more older
women within the population and that more women than men live alone in later life
(Arber and Ginn 1995), yet there is a higher risk of abuse occurring when people
live together. The different types of abuse that mistreatment consists of also do not
help to clarify the role of gender within such situations.
There are a further set of critical factors that need to be recognized when mis-
treatment of older people and the potential role of gender is considered. The soci-
etal, social, relational and cultural contexts concerning situations that happen need
to be carefully considered (Penhale and Parker 2008). As the phenomena of abuse
and mistreatment are socially constructed, it is essential that the meanings and
understandings ascribed to situations by individuals are properly taken into account
(Biggs etal. 1995). The structural context is the background in which mistreatment
is accepted and at the same time viewed as behavior that is permitted in society. To
this extent, ageism would seem to be a ‘master category’ in the power relationships
that affect older people (Penhale etal. 2000).
However, other intersectional interests such as gender and disability are clearly
of relevance and need to be properly considered in relation to this. In addition, we
also need to extend our knowledge and understanding of issues relating to both
gender and power relations (Brandl 2000; Brandl etal. 2003; Cooper and Crockett
2015; Crockett etal. 2015; Whittaker 1995) and the relative roles of these aspects in
the development and maintenance of both abuse and abusive situations. The concur-
rence and inter- relations between age, disability and violence are also of increasing
interest and concern and to these further intersections of gender and race might also
be usefully added. There is a clear need for intersectional approaches that incorpo-
rate the nexus of age, disability, gender and violence (Crockett etal. 2018). From a
life-course perspective, it is clear that so far less attention has been paid to the latter
stages of life, and this needs to be rectied.
Further, in the broad spectrum that comprises elder mistreatment, it is apparent
that there is a range of actions and behaviors (including some lack of actions and
some failures to act) that should be considered as indicative of abuse. When consid-
ering the range of mistreatment that exists, it is also clear that it is not just familial
and interpersonal relationships and violence that are relevant, but other aspects like
institutional forms of mistreatment are of importance and must to be taken into
account of (Stanley etal. 1999). We should also acknowledge that this ought to be
of particular disquiet when we consider that those individuals who are most likely
to be at risk of such harms are older disabled women– and they are also more likely
to be admitted to institutional care.
As stated, elder mistreatment should not be seen merely in the context of families
and interpersonal relationships. The uid nature of power relations and the continu-
ing prevalence of patriarchal assumptions are also linked to abuse within the context
of health and social care. Social and health care agencies accountable for ‘protective
responsibility’ (Stevenson and Parsloe 1993) may inadvertently or even overtly mis-
12 Gender Issues inElder Abuse
174
treat individuals to whom they owe a duty of care (Penhale and Parker 2008). In an
analysis of welfare and formal care provision, Jack (1994) suggested that depen-
dence, power and control were encompassed within care relationships and that
mutual (although unequal) dependency, powerlessness and violation frequently
results in and maintains abuse by formal carers.
In an early attempt to consider aspects of gender more appropriately, Whittaker
suggested that looking at differing types of abuse as being examples of ‘family vio-
lence’ or ‘carer stress’ results in an obfuscation of the effects of gender (Whittaker
1995). It is therefore proposed that the general concept of ‘elder abuse’ should be
more closely examined and that more emphasis should be given to the nature of
power within relationships, which would necessitate further consideration of gen-
der. This would also require recognition of the oppression of women as being
socially, economically and politically controlled by men, following feminist analy-
ses. Aspects of this control frequently occur in male violence against women; one
element of this is abuse between partners in a relationship (Whalen 1996). Therefore,
the degree to which such an analysis is appropriate in relation to elder abuse and
perhaps more particularly the abuse of older women still needs additional
exploration.
In terms of responses to abusive situations and potential service provision, a link
might also be usefully made when considering the use of refuges or “safe houses”
to offer protection for older women who have experienced abuse. The major pro-
vider of “Battered Women’s Refuges” (as they were originally named) in the UK,
Women’s Aid, have maintained a stance that they do not discriminate on grounds of
age and that their services are equally available for older women who have been
subject to abuse. However, for several different but inter-related reasons, it may be
unlikely that an older woman would choose to use such a resource. Nevertheless,
the development of safe houses specically for older women who have been victims
of abuse could be very useful, as this would be based on a very different set of
assumptions than the seemingly predominant model of institutional care as appro-
priate for elders who have been abused (Cabness 1989; Vinton 1992). Progress in
this area has been reported in recent years and looks set to continue, with at least one
refuge available for women older than 50years currently available in the UK.
12.3 Future Directions
One key area that requires further research is to try and determine the nature of both
commonalities and differences between domestic violence and the abuse of older
women. This would include a need to explore issues of dependency and vulnerabil-
ity that women may experience throughout the life-course and how these may alter
over time. We need to discover more about why certain people, such as women,
people with dementia and other mental and physical health difculties appear to be
at more risk of abuse (Penhale 1999b). Specically, identication of those factors
B. Penhale
175
that seem to render or increase individuals’ vulnerability would be helpful in the
search to resolve and even prevent abusive situations.
Some useful work has been undertaken concerning the use of screening tools for
abuse of older and younger women (Ejaz etal. 2001). Such work could perhaps be
extended to other related areas and different assessment formats in relation to
responding to mistreatment. Further to this, following consideration of the prelimi-
nary stages of screening and assessment, it would be useful to consider the extent to
which approaches to intervention in abusive situations experienced by women at
different stages of the life-course are shared or distinctive and the relative useful-
ness of such approaches. Action-research concerning the use of shelters, is an exam-
ple of such an approach that could be taken.
It would also seem appropriate to further examine the links between mistreat-
ment that takes place in domestic settings with that which happens in institutional
environments. More investigation of the settings in which abuse may occur is likely
to prove useful. Research that explores the nature and effects of power relations
both within relationships and different situations might nd some interesting areas
of correspondence between domestic and institutional settings. This would add to
knowledge and understanding of some of the key dynamics of abuse.
It also seems clear that not enough is known about which strategies of interven-
tion work best and are most effective in which situation to be able to state unequivo-
cally that a particular intervention is best for a specic type of mistreatment. This is
especially likely to be so in relation to under-researched areas like the abuse of older
disabled women. Evidently, work in this area needs to include the perspectives of
individuals on their situations and incorporating their views about the impacts of
mistreatment. These aspects will likely require more attention in future. Undoubtedly
the intersections between age, disability, gender and abuse are fundamental here;
establishing which perspective(s), preventive strategies and interventions will be
most helpful in meeting the requirements and circumstances of those whose needs
fall within these intersections is essential.
Finally, the societal and structural concomitants of abuse, such as the poverty and
oppression that many older people experience, would seem to be worth further
research. More in-depth investigation of aspects such as gender, power, disability
and ethnicity in situations of mistreatment would likely assist with this (Crockett
etal. 2018). This would be particularly pertinent as a means to try and establish the
extent to which such aspects both perpetuate abusive situations and exacerbate them
or even militate against their resolution. In addition to this, exploration of the links
between the oppression of older people (in particular older women) and that of
younger women or disabled people would also be of value in a wider consideration
of different aspects of interpersonal violence. This would include those areas that
are in common and shared and those that are distinctive to particular forms of vio-
lence and abuse. Further understanding of and knowledge about different types of
abuse and violence will clearly be useful in the efforts to prevent and resolve such
mistreatment in future.
12 Gender Issues inElder Abuse
176
12.4 Concluding Comments
In order to further develop the eld, a number of different approaches need to be
used. It is apparent that there is a need to improve awareness and recognition of
mistreatment, across the general public, professionals and perhaps most impor-
tantly, the older population. Work needs to happen to develop knowledge and under-
standing about abuse and neglect, and the inter-related aspects of causal factors and
consequences and the interplay of gender and power relations within such situa-
tions. Development of theoretical and conceptual frameworks and foundations are
also of central importance here (Ploeg etal. 2009; Podnieks etal. 2010) and these
need to include gender perspectives, as appropriate. Social perspectives on abuse
must also be fully incorporated in such frameworks. Above all, it is imperative that
the voices of older people, particularly those who have experienced abusive and
neglectful situations are central to such developments and that these include those
who are most marginalized and excluded, many of whom are women.
Several of these approaches will need thorough research and development to
happen. There is a need for intervention studies to be undertaken in order to ascer-
tain which techniques of intervention work best and in which circumstances. This
could include the development of model projects for different interventions, with
appropriate and rigorous evaluation of the different projects in order to determine
relevant areas for future development. Research on effectiveness and impact, not
just of interventions but also the impact of abuse and neglect, together with the
effect(s) of processes and interventions on individuals who have experienced or are
at risk of abuse and harm also needs to happen. Further work on the differing mod-
els of service provision (for example different types of specialist teams) should
occur, but as it is not clear yet which model might work best, and in which situation
or for which type of abuse; in-depth research and evaluation of such models would
be advantageous and would be likely to be useful for developmental reasons.
Likewise, it is also necessary to ensure that there is sufcient focus on individu-
alized and personalized approaches for those people who experience mistreatment
and harm; as far as possible these types of approaches should be tailored to the
needs of particular individuals. Key and central issues here relate to autonomy,
choice, empowerment, and, independence, with additional essential elements relat-
ing to individuals’ capacity and consent. Independence, self-determination and ser-
vice user-control are not necessarily in opposition to matters relating to individual
safety and protection. Indeed, most safety planning for older people aims to support
and empower individuals to keep themselves safe and to change their own situations
(if they are willing and able to do so). If we are to achieve the aim of assisting all
older people to live their nal years free from abuse, neglect and exploitation there
must be more research, development and international collaboration to further
counteract the differing and pervasive forms of mistreatment that exist. Attention to
issues relating to gender equality and the needs of older women will assist in this
endeavor.
B. Penhale
177
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A. Phelan (ed.), Advances in Elder Abuse Research, International Perspectives
on Aging 24, https://doi.org/10.1007/978-3-030-25093-5_13
Chapter 13
Danger inSafe Spaces? Resident-to-
Resident Aggression inInstitutional Care
ThomasGoergen, AnjaGerlach, SabineNowak, AnnaReinelt-Ferber,
StefanJadzewski, andAnabelTae
13.1 Introduction
In recent years, violence and abuse in caregiving contexts (both in institutional and
community settings) have increasingly become topics of research and discussion
(see, for example, Dong 2015, Lachs and Pillemer 2015, Yon etal. 2018). The main
focus of research is on the behaviour of caregivers towards care recipients, usually
addressed under terms such as ‘elder abuse and neglect’ or ‘mistreatment of older
adults’. Research also touches upon care recipients’ violence and aggression
towards professional and lay caregivers, often referred to as a type of ‘challenging
behaviour’ (e.g. Hazelhof etal. 2016; Pieper et al. 2016). For the eld of institu-
tional care, Fig.13.1 displays basic categories of interpersonal violent or aggressive
behaviour within and between the groups of nursing staff and residents. As a type of
workplace violence, physical and verbal aggression may also occur between profes-
sional caregivers (e.g. Berry etal. 2016). Only recently have phenomena of aggres-
sion and violence among residents started to gain attention. Based mainly on current
research from Germany, the chapter looks at these phenomena.
Rosen et al. (2008:1398) use the term ‘resident-to-resident aggression’ and
dene it as
…negative and aggressive physical, sexual or verbal interactions between long-term care
residents that in a community setting would likely be construed as unwelcome and have
high potential to cause physical or psychological distress in the recipient.
The focus of this denition is upon an interaction’s effects or consequences, while
at the same time emphasizing the importance of the context of ‘institutional care’
T. Goergen (*) · A. Gerlach · S. Nowak · A. Reinelt-Ferber · S. Jadzewski
German Police University, Muenster, Germany
e-mail: Thomas.Goergen@dhpol.de
A. Tae
Police University of Applied Science, Hamburg, Germany
182
for the perception and evaluation of (inter-) actions. Both the denition provided by
Rosen etal. (2008) and their abbreviation RRA for ‘resident-to-resident aggression’
will be applied throughout this chapter.
RRA research can be considered a challenging task. Ofcial statistics can hardly
be expected to provide a valid picture of aggressive incidents among nursing home
residents. Older care recipients, especially when affected by dementia and related
disorders, represent a ‘hard-to-reach population’ (Johnston and Sabin 2010) with
limitations regarding understanding of questions, reliability of answers, and capac-
ity to provide informed consent (see Quinn 2010). These very same limitations can
be assumed to be linked to both the probability of becoming a victim of RRA and
an RRA perpetrator. RRA research requires inclusion of multiple perspectives,
including (as far as possible) residents’ voices.
A recent review (Goergen 2017) provides an overview on international RRA
research. Some outlines of the current state of knowledge are summarized below.
• RRA is not limited to physical violence but includes sexual assault, verbal
aggression, humiliating behaviour, and forms of social exclusion. A collection of
cases handled by criminal courts points at the fact that RRA may lead to fatal
outcomes (Goergen 2017, see also Caspi 2018).
• While prevalence and incidence of RRA are hard to measure, several studies–
using different methodological approaches and different reference periods –
arrive at victimisation prevalence rates around 20% (of nursing home residents).
This may be taken as an indicator that RRA goes far beyond single isolated
cases. Existing research indicates that aggressive and violent behaviour is not
spread evenly over the resident population; rather– just as in violence in com-
munity settings– a small number of residents appear to be committing a large
proportion of all (severe) offences.
Person / group displaying aggressive /
violent behaviour
Nursing staff Residents
Person /
group
affected by
aggressive
/ violent
behaviour
Nursing
staff
(A)bullying /
lateral
workplace
violence
(B)care
recipients‘
‘challenging
behaviour’
towards
staff
Residents(C)elder abuse
and neglect
(D)resident-to -
resident
aggression
Fig. 13.1 A 2×2 scheme of aggressive interactions between nursing staff and residents in institu-
tional care
T. Goergen et al.
183
• Just as other types of violence (e.g. intimate partner violence, child abuse), RRA
affects physical and mental health and well-being and may have an impact on
institutional climate and quality of life in nursing homes. At the same time, conse-
quences of victimization are highly specic, depending not only on features of the
offence but also on victim characteristics (health, victimization history) and on
features of the social context, such as availability and quality of social support.
• RRA events are determined by multiple factors, including victim and offender
characteristics, situational cues, and organizational attributes. Connections
between physical health and functional capacity on the one hand and both victi-
misation and offending risks on the other, appear to be complex. Dementia may
be a background factor of aggressive behaviour but needs to be seen in a compre-
hensive perspective and in its interaction with variables such as pain and depres-
sion. Situational features such as noise, crowding, and invasion of personal space
may be relevant. Currently, little is known about the inuence of organisational
characteristics such as unit size, stafng, institutional climate and policies.
• For nursing staff, encountering aggressive behaviour by residents has some
degree of ordinariness; their coping strategies mainly develop against this back-
ground of everyday professional experience. They include measures aimed at
eliminating opportunities and triggers as well as de-escalation and mediation.
Nurses emphasise the importance of empathy towards residents and the motives
behind their behaviour for RRA prevention.
• Beyond the use of physical or pharmacological restraints, the development of
specic approaches addressing RRA is still in its beginnings. Approaches include
staff training, such as the SEARCH strategy (for Support, Evaluate, Act, Report,
Care plan, Help to avoid; see Ellis etal. 2014, Teresi etal. 2013), and changes in
the spatial environment.
13.2 Research onResident-to-Resident Aggression
inGerman Nursing Homes
The remaining section of the chapter will provide data from a recent German study
on ‘Resident-to-Resident Aggression in Long-Term Care’. The study received fund-
ing from the Federal Ministry for Family Affairs, Senior Citizens, Women and
Youth and was conducted in close collaboration between German Police University
(Muenster) and the Centre for Quality in Care (Berlin).
Before the study and selected ndings are presented, some basic data on caregiv-
ing and care dependency in Germany will be provided. At the end of the year 2015,
2.86million people drew benets from German Long-Term Care Insurance, 27% of
them living in institutions, and 73% in community settings. All over Germany,
13,600 nursing homes and day-care facilities with 929,000 beds and a staff of
approximately 730,000 were available. Eighty four percent of the workforce were
female; about half of the employees were skilled staff with specic training, usually
lasting several years. Thirty ve and a half percent of the beds were located in
13 Danger inSafe Spaces? Resident-to-Resident Aggression inInstitutional Care
184
double and multi-occupancy rooms. Forty two percent of the homes were in private
ownership, while 53% were run by charities. Among the residents, 51% were in the
85years+ range. The proportion of residents with ‘severely impaired everyday com-
petence’ (a term formerly used in German Long-term Care Insurance Law) in nurs-
ing homes amounted to 71% and was signicantly higher than among care recipients
in community settings (31%; see Statistisches Bundesamt 2017). German nursing
homes are regulated under governing legislation. Compliance with the federal and
state legislatures are reviewed regularly for adherence to standards of building
codes, care plans, nutrition and dietary services, medical services, nursing and per-
sonal care, and recreational programs (Schmitz and Schnabel 2006).
13.3 Study Aims
The main aim of the study was to provide quantitative and qualitative data on RRA
in institutional eldercare in Germany. This refers to the phenomenology of violent
and aggressive behaviour (including characteristics of persons involved in aggres-
sive episodes, and situational and context characteristics), its (perceived) preva-
lence, and consequences of RRA incidents, triggers, risk factors and protective
factors. The second main aim was to analyse the signicance of RRA incidents for
everyday nursing work and other groups of practitioners, the ways in which staff
and institutions handle such incidents and cope with them.
13.4 Research Design
The study follows a mixed-methods approach. Its rst component is a quantitative
paper-and-pencil survey (35 questions on 12 pages) among staff in long-term care
institutions for the elderly. This survey covers experiences of RRA and respondents’
experiences with aggression of residents directed at staff, known as challenging
behaviour (Hazelhof etal. 2016; Pieper etal. 2016) or ‘resident-to-staff-aggression’
(RSA) (Lachs etal. 2013), as well as institutional handling of cases, individual cop-
ing behaviour and education and training needs.
Questions on RSA and RRA as well as on location and timing of incidents have
been developed on the basis of measures used by Lachs etal. (2016). RSA was mea-
sured with 13 questions and RRA with 15 questions (each also had an open answer
eld for ‘other behaviour’, cf. Answer categories were ‘no’, ‘yes, once’, and ‘yes,
multiple times’ and referred both to the time since the respondent joined the current
institution and to the last 4weeks. Consequently, prevalence could be measured as
time-in-institution-prevalence (tip1) and as 4-weeks prevalence (4wp) (Table13.1).
1 Tip-prevalence stems from the question (e.g.): ‘Have you, since you have been working in this
institution, ever experienced that a resident has screamed at you?’
T. Goergen et al.
185
Furthermore, an additional institutional survey with 14 questions on four pages
was sent to the nursing home management in the participating facilities. The ques-
tionnaire mainly focussed on socio-demographic data of residents, institutional
ownership, size of the nursing home, care levels (indicating degree of care depen-
dency and support needs), and number of court-ordered legal guardianships among
the residents.
The staff sample was composed of 1326 persons who are employed or work in
care and assistance of residents, from 72 long-term care facilities in the federal state
of North Rhine-Westphalia. The majority of the long-term care facilities were run
by charities (n=49), four facilities were run by municipalities (or other public bod-
ies) and 19 were private enterprises. The state of North Rhine-Westphalia has a
population of nearly 18 million. Several large cities (above 100,000 inhabitants),
smaller cities (20,000–100,000 inhabitants) and villages (below 20,000 inhabit-
ants.) have been selected as a proportionate stratied random sample of municipali-
ties. Within each municipality, institutions were selected via simple random
sampling. The response rate of participants was 31.8%. The survey was conducted
between June 2017 and March 2018.
The second methodological approach to RRA was an in-depth interview study in
four nursing homes, addressing residents as well as staff, probing into experiences
with violence and aggression in residential care. The study was conducted using
separate semi-structured interview guidelines for staff, management and residents,
as well as templates recording social data, and interview postscripts. The staff inter-
views centred on verbal, physical and sexual resident-to-resident aggression the
interviewee had witnessed, ways of dealing with violent episodes, and education and
training in this respect. In addition, nursing and other staff were asked about their
personal experiences with aggressive acts perpetrated by residents, management
were asked about strategies for preventing resident–to-resident aggression in the
institution. The interview guideline for residents focussed on life in the institution,
in particular on conicts or violent episodes the interviewee had experienced or
observed. All interviews were recorded and transcribed verbatim for analysis.
Table 13.1 Measures for RSA and RRA experienced responses observed by nursing home staff
Type of behaviour Behavioural categories
Verbal aggression
5 questions
Screaming at someone; insulting someone.; bossing someone around;
intimidating or verbally threatening someone; threatening with st, cane,
other object
Physical aggression
6 questions
Hitting or kicking someone; roughly grabbing or yanking someone;
throwing things at someone, pushing or shoving so; deliberately spitting,
scratching or pinching someone; ramming someone with a walker or
wheelchair
Sexual acts/
harassment/assault
3 questions
Using inappropriate sexualised language towards someone; touching
someone in a sexually harassing manner; intimately touching oneself in
front of someone (last item RRA only)
Other behaviour Walking into another residents’ room and touching, damaging or taking
his/her belongings (RRA only)
13 Danger inSafe Spaces? Resident-to-Resident Aggression inInstitutional Care
186
During the study in 2017 and 2018, 80 participants were interviewed, of which
56 were members of staff (including management) and 24 were residents of four
long-term care facilities in North Rhine-Westphalia. From all municipalities in the
Muenster administrative district (Regierungsbezirk Muenster), two large cities, one
smaller city and one village were selected as study areas by way of random sam-
pling. Within each of the four municipalities, one long-term care facility was
selected. This was done sequentially and at random, but taking into account varia-
tion in facility size and ownership. In each of the four facilities, 20 participants were
interviewed, of which 14 were staff/management and six were residents. Staff mem-
bers and residents were randomly sampled by way of anonymized staff lists or by
lists of room numbers, both provided by the facility’s management. Members of
staff that did not work in nursing were to be included in the list if they spent at least
half their working time in direct contact with the residents. Residents who were
ultimately not suitable for interview were only excluded after the sampling process
and only after careful consideration and with a documentation of reasons.
13.5 Findings
13.5.1 Findings fromtheSurvey
Sample 85.3% of the 1317 respondents were female, which closely matches the
overall distribution for nursing home staff in Germany of 87% in 2015 (Statistisches
Bundesamt 2017).
Most of the participants worked as qualied nurses (n=523) or care assistants
(n=436), but staff from numerous other occupational backgrounds were included
in the survey, such as social workers, therapists, untrained staff and more. Since the
survey addressed all persons afliated with care and assistance of residents and thus
included some honorary helpers (n=19), the age range of respondents varied from
17 up to 85years (M =44.3years). Length of employment/activity in the current
institution (n=1310) was quite high (10years or more=33.3%; 5-10years = 21.9;
1−5years = 32.8%; <1years =12%).
The large majority of participants (88.2%) stated that German was their mother
tongue (including bilinguals). This characteristic served as a proxy variable for
migration background. A German study conducted in 2015 estimated the percent-
age of nursing staff with migration background to be in the 15–23% range (Kohls
2015); thus, there may be a small participation bias in our survey (that was con-
ducted in German language only).
Experiences with RSA and RRA When asked about their own experiences with
RSA, reports of participants show a high time-in-institution-prevalence (tip), as
well as four-weeks-prevalence (4wp) for verbal and physical victimization. Sexual
acts, (verbal) sexual harassment or sexual assault through residents were reported
less frequently, but still seem to occur on a regular basis (Table13.2).
T. Goergen et al.
187
Observation of resident-to-resident-aggression is similarly widespread
(Table13.2) and multiple forms of violence have been witnessed by participants.
Also, 70% of participants (tip, n=1310; 4wp: 48.7%, n=1249) observed/expe-
rienced that a resident went into another resident’s room and touched, damaged
or took his/her belongings. Only 8.3% (n = 1322) of the participants did not
indicate any RRA-incidents. Nearly all of those (n=101) had comparably small
‘windows of opportunity’ to encounter RRA since they either held positions
with limited hours of contact with residents (e.g. as volunteers or kitchen staff)
or had only recently started to work in the institution included in the survey.
Detailed information on the most recent RRA-incident observed was provided
by 74.4% (n=1197) of the participants. Mostly, incidents started in places where
residents regularly meet other residents, such as dining rooms, hallways, or com-
mon rooms. In the majority of incidents specied, two residents (77.8%) had gotten
into a conict with each other. Just over 13.2% of the participants reported that three
persons had been involved. In 9% (n=855) of the last observed incidents, four or
more residents were involved in the conict. When asked for their views on possible
triggers and causes of the last observed RRA-incident, participants (n=872) mostly
described that certain dynamics between residents lead to the conicts: A resident
felt disturbed (45.1%) or hassled (18.8%) by another or was jealous (13.2%) of
another person; 31% stated that residents had an argument among each other. Often,
a resident’s poor capacity to communicate was named as the cause of the incident
(resident was stressed because he/she could not understand a situation: 33.5%, resi-
dent was disoriented: 24%, resident had problems with speech/communication:
18.2%). Other possible triggers or causes for incidents indicated by participants
were that a resident was impatient (29.1%) or anxious (7%) that his/her request was
denied (3.8%), and that he/she felt disrupted by daily routines (5.3%). Noise in the
residential area was mentioned in further 9.9% of the incidents as one (of the)
cause(s), and in 12.4% participants stated, that the incidents occurred when stafng
was insufcient or staff was under pressure of time (7.3%). Respondents often
named multiple causes and triggers for the last observed incident, so gures add up
to more than 100%.
Table 13.2 Overview on time-in-institution and four-weeks-prevalence of RSA and RRA
behaviour
Experienced/observed behaviour
RSA: tip %
(1313≤N≤1317)
RRA: tip %
(1316≤N≤1320)
4wp %
(1238≤N≤1283)
4wp %
(1265≤N≤1297)
Verbal aggression 87.3 88.5
63.4 69.3
Physical aggression 70.0 60.1
37.6 33.3
Sexual harassment/assault 42.5 27.4
14.3 9.9
13 Danger inSafe Spaces? Resident-to-Resident Aggression inInstitutional Care
188
Participants were also asked to provide information about the residents involved
in this most recent incident (if there were more than two, the two persons considered
to be most strongly involved were to be chosen). Characteristics can be compared
between residents who–as perceived by respondents-started the argument (n=673)
and residents who did not start the argument (n=576). They will be referred to as
‘initiators’ and ‘targets’ below.
The gender of initiators (68.1% female) and targets (75.9% female) involved in
the arguments is in line with the overall sex ratio in German long-term care facilities
(72% female, cf. Statistisches Bundesamt 2017, p.8), though there is some over-
representation of men being initiators and women being targets in the conicts.
There are barely any differences between initiators and targets regarding their age,
apart from initiators belonging more often and targets less often to the group of the
very old (80years+: targets = 50.9%; initiators = 47.9%). Targets are more often
limited in their abilities to communicate, to hear, or in their mobility, but cognitive
loss is a characteristic present in both groups with around 60%. Among initiators,
diagnoses of psychoses and addictions are more prevalent (but still only little under
10%), whereas targets are slightly more often diagnosed with dementia than initia-
tors (62.3% vs. 55.4%).
13.6 Experiences withandPerceived Importance
ofEducation andTraining
Half of all participants (49.9%) had already learned about aggression and violence
in nursing care as part of their job training. During the last 12months, 27.1% of all
participants (n=1263) had attended trainings related to these topics. Among the key
topics of these trainings, measures to ‘handle aggressive resident behavior’ were
most frequent (16.8% of all topics mentioned by respondents), followed by ‘causes
and triggers’ for (16.1%) and ‘prevention’ (13.3%) of such behavior (n=334).
The vast majority of all participants (n=1309) considered continuing education
and training on aggression and violence in nursing care to be ‘quite important’
(25.5%) or ‘highly important’ (68.6%). They would like to learn more about tech-
niques of de-escalation (76.1%; n=1198) and safeguarding at the workplace (53.6%)
as well as about coping with psychological stress caused by aggression and violence
at the workplace (46.7%). So far, only 19.7% (n=1264) had participated in some
training on interacting with potentially aggressive persons. If participants had received
relevant further education or training, approval of the perceived importance of such
measures was even higher (n=341): 77.1% considered them to be ‘highly important’,
20.2% said they were ‘quite important’ and only 2.6% considered them as just ‘some-
what important’ (overall sample: 5.7% plus 0.2% ‘not at all important’).
T. Goergen et al.
189
13.7 Findings fromtheInterview Study
The survey presented thus far has pointed out the high prevalence of RRA in German
nursing homes and underlined the perceived importance of training staff to ade-
quately respond to these more or less daily occurrences. The next section will focus
on an in-depth view at opportunities and shortcomings of (further) training to han-
dle RRA incidents adequately. The following results are derived from guided inter-
views with 42 interviewees, including 14 management staff and 28 qualied nurses
and other staff (e.g. social workers, service staff, care assistants) in three nursing
homes in the German federal state of North Rhine-Westphalia in 2017 and 2018.
Resident-to-Resident Aggression–A Disregarded Phenomenon Many interview-
ees reported episodes of RRA in which staff were, due to lack of training, were
either not helpful or even themselves the source of the problem– because they did
not deal with residents in a manner appropriate to their health and functional status,
which made them nervous or aggressive, or because they were not able to identify
aggressive cues and avert aggressive behaviour.
Most of the management and staff interviewed considered education and training
to be highly important for working with residents, in particular when dealing with
RRA.Many, however, expressed concern for the lack of training and skill, be it their
own or others’, when handling aggressive episodes. Both vocational and further
training were described as lacking with regard to handling RRA episodes.
Vocational Training According to the interviewees, resident-to-resident aggres-
sion does not play a central role in the vocational training of nursing staff and other
staff. Instead, the topic ‘violence’ is only covered briey in training.
While most of the qualied nursing staff interviewed had been trained regarding
aggressive behaviour between residents and staff, many felt helpless or insecure
when observing incidents of RRA.As several interviewees thought, even the three-
year training programme qualied nurses undergo does not necessarily provide the
skills and competencies to handle resident-on-resident aggression.
Where even fully trained nurses lack expertise in handling RRA, assistant staff
with little or no training were characterized by several interviewees as lacking skill
and sensitivity when detecting and possibly averting residents’ aggressive episodes.
As one interviewee, a head nurse of a ward put it:
Yes, denitely. This is-. It’s obvious with colleagues who only have a two-year-training or
often just a one-year training. Also with care assistants, they deal quite differently with the
residents. Often you can prevent aggression by simply knowing the residents and simply
paying attention to their reactions.
As the interviewee describes, less thoroughly trained staff often do not know how to
interpret the residents’ specic cues and are thus unable to prevent aggressive
reactions.
Several interviewees spoke of a recent trend to focus qualied nursing staff on
hands-on medical tasks, e.g. hygienic and medical duties, and leave the rest (look-
13 Danger inSafe Spaces? Resident-to-Resident Aggression inInstitutional Care
190
ing after the residents, paying attention and simply ‘being there’) to care assistants
and other assistant staff. They considered this problematic, particularly with regard
to RRA.Interviewees thought this separation leaves residents at many times in the
sole care of poorly trained or untrained staff who are not equipped to detect specic
aggressive cues, prevent escalation or intervene in violent situations among resi-
dents. As a social worker put it:
[…] And then they must, the staff surely need to be trained as well. For example, I still see
opportunities for expansion, in general in the training of nursing assistants and nurses.
Because we work with human beings and I have the expectation that we care properly for
people, especially for those with dementia, and I don’t think it’s appropriate that we let
rather untrained people do this work. This is a very, very sensitive topic and a very sensitive
eld of work. And people react very strongly, emotionally. Especially dementia patients.
That's why aggression can happen, in fact. And those who have no knack for it and who lack
a certain attitude und who might not even be properly trained, in my opinion they have no
place in such an institution.
Further Training Programs As interviewees felt the basic training program
lacked a focus on dealing with RRA, many of them thought the relevant skills
needed to be taught in further training programs. Despite this perceived need for
further training, however, several interviewees felt the further training courses
available in their institutions were not adequately designed in order to prepare staff
to handle aggressive incidents between residents. They said the programs had little
or no focus on RRA, were not offered on a regular basis, or mostly addressed quali-
ed nurses. According to many interviewees’ experience, less qualied staff, who
could prot most from further training, were either not among the target groups of
existing trainings or they chose not to participate. Another matter pointed out by
several interviewees was the lack of practical examples in basic and advanced train-
ing programmes: they felt the available training programmes were too general so
that they failed to improve the skills of the staff when handling difcult situations
like RRA.
Training and Capacity to Handle RRA Whereas RRA clearly is a highly impor-
tant challenge for care institutions for older people, the staff interviewed reported a
rather low level of competencies and skills in dealing with aggressive behaviour
amongst residents. While many clearly see a need for education and training, not
enough is currently done in the institutions that participated in our study. It can be
assumed, moreover, that there is a certain participation bias: the institutions that
agreed to participate and devote part of their staff’s working time to the project are
likely to face the problem in other ways as well, whereas institutions that refused to
participate might be even less well prepared to deal with RRA. It can thus be
assumed that having a greater focus on RRA during education and training would
improve the staff’s overall ability to detect, avert and handle aggression amongst
residents. In particular, educating and training assistant staff seems crucial for them
to be able to adequately perform their growing duties.
T. Goergen et al.
191
13.8 Conclusion andImplications forInstitutional Policies
Resident-to-resident aggression is not merely a ‘newly discovered’ facet of elder
abuse or elder mistreatment. Unlike elder abuse, it is not bound to relationships with
an ‘expectation of trust’2 and has older care recipients on both sides of the victim–
perpetrator dyad. Like elder abuse, it impacts health and quality of life and its fre-
quency and intensity can be regarded as a quality indicator in institutional long-term
care.
The survey among people providing work in German nursing homes shows that
staff encounter both resident-to-resident aggression and residents’ aggressive
behaviour directed towards themselves. Four out of ten respondents have experi-
enced physical aggression from residents during the last 4weeks, and three out of
ten have witnessed physically aggressive behaviour between residents during this
short time frame. RRA episodes are often located in shared spaces within the nurs-
ing home (where they also have the greatest chance of being witnessed). Respondents
name multiple causes and triggers for RRA, including individual characteristics,
interpersonal dynamics, and physical and social features of the institutional
environment.
Both the standardised survey and the interviews conducted in German nursing
homes point at the key role of vocational training and continuing education for pre-
vention and successful handling of RRA and aggressive incidents in general.
Understanding of circumstances potentially leading to aggressive behaviour, detec-
tion of ‘early warning signals’, strategies of de-escalation and handling of violent
incidents can be improved through training. At the same time, attention needs to be
given to the design of the spatial environment (e.g. in order not to create spaces
where crowding and violation of personal space are highly probable).
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A. Phelan (ed.), Advances in Elder Abuse Research, International Perspectives
on Aging 24, https://doi.org/10.1007/978-3-030-25093-5_14
Chapter 14
An Ecological Perspective onElder Abuse
Interventions
AmandaPhelan andDeirdreO’Donnell
14.1 Introduction
Elder abuse is a complex phenomenon which permeates all societies. As global
aging occurs (WHO 2016), it is imperative that systems of safeguarding target both
prevention and intervention. This chapter applies a socio-ecological lens to examine
interventions within the published literature and is based on a study undertaken by
the Irish National Centre for the Protection of Older People (NCPOP), University
College Dublin (O’Donnell etal. 2015). The review included papers which described
interventions using descriptive and qualitative designs as well as papers which eval-
uated the efcacy of interventions using experimental designs. The chapter com-
mences with giving a brief review of elder abuse and then presents the ndings of
the NCPOP study (O’Donnell etal. 2015). The ndings are categorized into descrip-
tive and experimental designs and presented accordingly.
14.2 Elder Abuse
Based on a denition from Action on Elder Abuse (1995), a charitable organization
in the United Kingdom, the World Health Organization (WHO) (2008) describes
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.
A. Phelan (*) · D. O’Donnell
National Centre for the Protection of Older People, School of Nursing, Midwifery & Health
Systems, University College Dublin, Beleld, Dublin, Ireland
e-mail: Amanda.phelan@ucd.ie
194
While this denition provides some insight into what constitutes elder abuse, it
does have limitations. Firstly, there is a focus on relationships, suggesting abuse is
dened by the person who commits the act and not the act itself (Phelan 2018).
Another challenge is that elder abuse, like beauty, can be in the eye of the beholder.
For example, is abuse not abuse if there is no harm or distress to the older person?
Other concerns center on the denition’s over-inclusive nature (Brammer and Biggs
1998) and the lack of distinction of elder abuse and other forms of interpersonal
conict (Mowlam etal. 2007). This has led countries like Ireland to revise deni-
tions to enable more clarity and to include a human rights dimension (HIQA 2013,
Social Care Division 2014:8) as detailed below:
… any act, or failure to act, which results in a breach of a 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 nancial transactions to which the
person does not or cannot validly consent, or which are deliberately exploitative. Abuse
may take a variety of forms.’
Since elder abuse’s formal identication (Baker 1975; Burston 1975), under-
standings have increased with a delineation of typologies: physical abuse, sexual
abuse, nancial/material abuse, psychological abuse and neglect. The area of self-
neglect has been contentious with its inclusion in some jurisdictions while being
excluded in others (Phelan 2013). However, there are also differences in these cat-
egories when older people themselves dene elder abuse (WHO and INPEA 2002;
Erlingsson etal. 2005; Mowlam etal. 2007; Age Action Ireland 2011). In such stud-
ies, older people identify issues such as abuse of rights, social exclusions and com-
promization of decision- making (Phelan 2013).
In terms of the prevalence of elder abuse, it has been shown to occur in any set-
ting (Naughton etal. 2010; Drennan etal. 2012). The WHO (2016), based on pub-
lished prevalence studies, estimates that 1:6 older people are abused with a much
higher prevalence in those who have cognition challenges and decision-making
challenges (see Phelan and Rickard Clarke, Chap. 3, in this volume). As most older
people live in the community, it is unsurprising that most abuse occurs in the home
environment with family members being the most common abuser (Phelan 2018).
Furthermore, psychological abuse (33%) is identied as the most common form of
abuse with nancial abuse and physical abuse constituting joint second (14%)
(WHO 2016). However, individual studies vary from as low as 2.2% in Ireland
(Naughton etal. 2010) to 18.4% in Israel (Lowenstein etal. 2009). It is likely that
such studies are underestimates, with many cases being under-reported (Lifespan of
Greater Rochester etal. 2011; Lachs and Pillemer 2015). Risk factors, with varying
empirical support, have been identied as being related to the older person (physical
and cognitive health, age, gender, nancial dependency, ethnicity, dependency), the
perpetrator (substance abuse, mental illness, dependency on the older person), rela-
tionship (victim and perpetrator, marital status), geographical location and societal
norms (attitude to older people, cultural norms) (Kosberg and Garcia 1995; Phelan
2013; Pillemer etal. 2016; Yunus etal. 2017).
The consequences of elder abuse are diverse. These include social isolation,
depression, anxiety (Dong etal. 2013) and suicide ideation (Wu etal. 2013). Abused
A. Phelan and D. O’Donnell
195
older people are more likely to report chronic pain (Fisher and Regan 2006) and
being abused has been associated with a higher rate of admissions to hospital and
long term care facilities (Dong and Simon 2013), as well as higher mortality rates
(Schoeld etal. 2013) and morbidity rates (Dong and Simon 2013, Fisher et al.
2011). In addition, there is a cost of addressing elder abuse within health budgets
(Dong 2005; Jackson 2009a).
14.3 Responding toElder Abuse Using aSocio-ecological
Approach
In examining aspects of elder abuse, it is clear that it is a multi-faceted societal issue
that has little evidence regarding interventions efcacy (Ploeg et al. 2009; Sethi
etal. 2011; Stein 2017). However, there is an urgent need to have evidence-based
interventions that are cost-effective and sustainable (Pillemer etal. 2016; Du Mont
etal. 2015), particularly in the context of a global demographic shift to aging popu-
lations (O’Donnell et al. 2015). Consequently, responses are needed at multiple
levels to address the total context of abuse perpetration. Yet, such robust evidence is
elusive (Alt et al. 2011; Ploeg et al. 2009). Using a socio-ecological model
(Bronfenbrenner 1979) has the advantage of targeting understanding and responses
from the microsystem of the older person’s immediate environment to the macro-
system of the policy and legislation. Bronfenbrenner (1979) initially used the lens
of a socio-ecological model in child protection arguing that a child is immersed in
complex systems (microsystem, mesosystem, exosystem, macrosystem and chrono-
system) which interact with each other and can either heighten risk or safeguard the
child. Since then, the socio-ecological model has been applied to the domain of
elder abuse (O’Donnell etal. 2015; Dow etal. 2018) and the sphere of family vio-
lence in general (Dahlberg and Krug 2002; WHO 2018; Centre for Disease Control
and Prevention 2018). We adapted Bronfenbrenner’s (1979) model to represent a
systems level intervention as presented in Table14.1. As the majority of the litera-
ture represented single point studies, we omitted the chronosystem as this repre-
sents a change over the time dimension.
14.4 Identifying theLiterature: Systematic Search Strategy
In this chapter, we draw on work undertaken in the National Centre for the Protection
of Older People (O’Donnell etal. 2015). Within this study, we undertook a search
of nine databases (EBSCO (Academic Search Premier, CINAHL, Lista), PubMed
(Medline), Web of Science (Social Science/Science Citation/Arts and Humanities),
OvidSP (Medine/PsychInfo) for the period of January 2000–October 2013. Both
single and combination terms were used for elder/old, intervention, prevention, care
14 An Ecological Perspective onElder Abuse Interventions
196
and service. MeSH terms for elder abuse and mistreatment were also used.
Additional strategies were used to include previous systematic reviews, manual
searching of the National Centre for the Protection of Older People’s database and
ancestral searching was used to enhance the literature search. Using the World
Health Organization (WHO) (2008) denition of elder abuse, only English lan-
guage texts were reviewed and ‘older people’ related to those over 50years of age.
Retrospective and prospective studies were included as well as studies using an
experimental or descriptive design. Screening tools, book chapters, book reviews,
systematic reviews, strategy reports and literature appraisals were not included.
This resulted in 7170 citations, of which 5417 were eliminated due to not being
relevant or ineligibility. Of the remaining 1753, 1545 were eliminated through a
review of title and abstract. A full-text read of the remaining 208 articles eliminated
a further 104 publications. The remaining 104 were included in the review of which
67 were identied as non-experimental descriptive studies and 37 experimental
studies.
14.5 Categorizing Retrieved Interventions
Following the literature reduction, each article was carefully read and categorized
into the adapted Bronfenbrenner (1979) model as detailed in Table 14.1. Two
researchers engaged in inter-rater reliability of categorization. As some papers rep-
resented the same intervention (i.e. intervention resulted in more than one publica-
tion), the review identied 98 unique interventions. If any publication had
interventions which spanned the systems, the researchers agreed on placement in a
dominant system (Table14.2).
Table 14.1 Adapted Bronfenbrenner’s (1979) model to elder abuse interventions (O’Donnell
etal. 2015)
Systems-level Categorization
Microsystem Interventions directly targeting the older person who is or is at risk of
experiencing abuse within immediate contact, for example, home environment,
residential care home, community.
Mesosystem Interventions that target the connections between the micro-systems (family,
friends, community group). This system also included interventions which
involved caregivers (formal and informal), family, social network and
community networks.
Exosystem Interventions which include links between the individual’s immediate context
and a social setting within which the individual does not have an active role
(adult protective service, criminal justice systems, social welfare system, health
system, political system)
Macrosystem Interventions that focused on the over-arching culture, such as values and
beliefs of societies, socio-economic status, identity and heritage, and
discriminatory social values that foster abuse.
A. Phelan and D. O’Donnell
197
The evaluation of the descriptive designs followed Jackson’s (2009b) criteria for
presenting the phenomenon as it naturally occurs. Descriptive designs contained
case studies, discussion papers, observational studies, program evaluation surveys
and papers on service reform or educational initiatives. Experimental design papers
were evaluated using Rychetnik et al.’s (2002) evaluation of public health interven-
tions which examines if the research design was good enough, what were the
research outcomes and is the research transferrable.
14.6 Microsystem
A total of 18 papers were included in the microsystem level, which encompassed
interventions that directly involved the older person. Within the descriptive design
papers, these included a review of individual case management, which could be
general elder abuse cases or specic typologies (Heath etal. 2005; Istenes et al.
2007; Morris 2010; Vladescu etal. 2000) or case relating typologies (Koenig etal.
2010; Malks etal. 2002; Sacks et al. 2012) to gender (Tetterton and Farnsworth
2011). While most focused on responses to elder abuse being perpetrated, one paper
discussed an intervention that had a preventative focus (Alon and Berg-Warman
2013).
Another intervention included creating referrals into Linking Geriatrics to Adult
Protection (LGAP) to concurrently address unmet health needs in addition to safe-
guarding needs. Following the assessment of the older person’s case, ve interven-
tions were available, which included guardianship, hospital admission, home help,
institutional placement or medication initiation. Of the older people referred, 81%
required one or more intervention and guardianship and institutional placement
were found to have signicance for case management. A similar intervention in
Colorado, the Team Elder Abuse Mistreatment Project of Summit County also pro-
vided an interagency approach (geriatrician, social worker, probate court investiga-
tor, sheriff’s department, aging agency, adult protective service) (Istenes et al.
2007). Although the sample case size was small, the study reported a 100% case
success. Having a dedicated support service, specializing in elder law (Morris 2010)
was also identied as reducing the older person’s stress as well as making the legal
engagement more efcient. Equally, Vladescu et al. (2000) reported on an
Table 14.2 Systems levels and study design type
Systems level Experimental design Descriptive design Total
Microsystem 5 13 18
Mesosystem 25 27 52
Exosystem 3 20 23
Macrosystem 1 4 5
Total 34 64 98
14 An Ecological Perspective onElder Abuse Interventions
198
empowerment- based intervention, however, it was noted that the increased length of
time on cases in this Seniors’ Case Management Programme did not correlate to
increases in positive case outcomes.
Koenig etal. (2010) presented an ethical framework for managing cases of older
adults who were hoarders, however, it was propositional in nature and would require
practical implementation and evaluation. In exploring cases of abuse of older
women, Tetterton and Farnsworth (2011) emphasized the building of rapport to
underpin therapeutic relationships, however, the paper was based on only two elder
abuse cases.
Malks etal. (2002) examined the multi-disciplinary Financial Abuse Specialist
Teams (FAST) which had the discretion to freeze assets when nancial abuse was
suspected and undertake investigative activities. The authors acknowledged that
multi-disciplinary collaboration and staff support were essential to the program’s
success. There was a rise of referrals by 60%, demonstrating efcacy. Similarly,
Sacks etal. (2012) examined the impact of Daily Money Management programs
from eight private non-prot agencies providing such services and suggest that such
programs can act as a deterrent to the older person experiencing nancial abuse.
Combatting tele-fraud through the National Telemarking Victim Fraud Centre was
examined in a study by Aziz etal. (2000). This intervention applied proactive target-
ing of older people whose names were listed in a MOOCH list. A MOOCH list
holds information on people vulnerable to nancial abuse and can be sold on for
further exploitation. In the rst year, almost 20,000 calls were made and there were
68 older people who had received fraud-related calls, however, the study did not
explore the impact of preventative education.
A total of ve experimental evaluation studies were retrieved and categorized in
the microsystem ecological level (Acierno etal. 2004; Dyer et al. 2002; Filinson
1993; Mariam etal. 2015; Wilber 1991). The ve interventions classied at this
ecological level were:
• a 15-min educational video and corresponding brochure aimed at educating
older people who experienced criminal victimization, as to healthy coping and
safety planning strategies (Acierno etal. 2004);
• an interdisciplinary geriatric assessment and intervention program which tar-
geted the psychological and social well-being of patients referred by adult pro-
tective services (Dyer etal. 2002);
• a volunteer advocate program which provided assistance and advocacy to older
people experiencing abuse with a particular focus on providing support in the
utilization of the criminal justice system (Filinson 1993);
• a program which sought to mobilize the social and psychological resources of
older people considered at risk of abuse and/or self-neglect by targeting their
relations with family and their community (Mariam etal. 2015);
• and a daily money management program which sought to divert older people,
referred to protective services, from conservatorship (Wilber 1991).
Three of the studies evaluated interventions using an experimental design, which
incorporated a comparative control group (Acierno et al. 2004; Filinson 1993;
A. Phelan and D. O’Donnell
199
Wilber 1991). Two of the studies employed a quasi-experimental design, typically a
pre and post-intervention evaluation, to generate evidence for intervention efcacy
(Dyer etal. 2002; Mariam etal. 2015).
14.6.1 Summary
While some positive outcomes were found in the descriptive studies, in considering
the literature presented in relation to microsystems’ level, it was concluded that
evidence to support any particular intervention at this ecological systems level was
weak in relation to the small samples sizes, risk of bias, intervention implementa-
tion and outcome measurement (O’Donnell etal. 2015). This highlights the need to
further robustly examine the potential of microsystems interventions to safeguard
older people at risk of or experiencing abuse.
Of the ve experimental papers included for review which were classied at this
ecological systems level, the strongest evidence for efcacy was found for a psycho-
logical and social support intervention targeting at-risk older people (Mariam etal.
2015) and an educational video and corresponding brochure aiming to educate older
people who experienced criminal victimization (Acierno etal. 2004).
14.7 Mesosystem
The mesosystem included interventions which had an impact on the older person
but did not involve direct contact and tended to be evaluations of programs. This
systems-level contained the highest number of elder abuse interventions (n=52).
For the descriptive studies (N=27), these can be sub-divided into case manage-
ment service models and educational initiatives, while the experimental design was
sub-divided into support groups for older people, interventions targeting perpetra-
tors, interventions targeting informal caregivers, interventions targeting rst respond-
ers, interventions targeting nurses and nursing assistants, interventions targeting
physicians and interventions targeting multi-disciplinary healthcare providers.
14.7.1 Case Management Service Models
Service models which provided elder abuse training and specialist response systems
were shown to be important in terms of raising staff awareness and effective case
management and the identication of appropriate pathways which mapped to the
abuse severity and type (Alon and Berg-Warman 2013; Wolf and Pillemer 2000) as
well as family systems and risk management approaches. Interventions could
include counseling, support groups, day care, home care, medical treatment or legal
14 An Ecological Perspective onElder Abuse Interventions
200
support, however, functional impairment impacted on achieving case resolution,
while addressing caregiver stress was important (Wolf and Pillemer 2000). In Alon
and Berg-Warman’s (2013) Israeli study involving three municipalities, a Specialized
Unit for the Prevention and Treatment of Elder Abuse (SUPTEA) was established
which comprised of a social worker and paraprofessional linked to an advisory
multi-disciplinary team. The were two objectives-screening for risk and the provi-
sion of interventions such as one to one counseling, family mediation and group
work. A second focus was public awareness raising. In tandem with SUPTEA, 40
social workers received two elder abuse training programs. The evaluation was
undertaken through questionnaires (N=558, social workers) and interviews (abus-
ers, victims, professionals) and observations of group work. Findings pointed to
improved case management procedures and the closure of almost a third of cases,
with a further resolution in 18% of cases.
Wolf and Pillemer (2000) explored case management in 59 cases of elder abuse
in three elder abuse response programs. Findings pointed to the importance of case
variables such as abuse severity, the stress of the older person and perpetrator and
type of abuse. Intervention success also relied on approaches to self-determination,
family preservation and openness to the intervention by the family. The authors,
based on the ndings, pointed to the importance of a family systems approach to
case intervention (Wolf and Pillemer 2000).
Having a variety of professionals within a dedicated multi-disciplinary team was
considered particularly useful as each member brought their disciplinary experience
to cases and working together increased communities of practice in responding to the
myriad of complexities inherent in elder abuse (Teaster etal. 2003; Twomey etal.
2010). However, having good leadership with multi-disciplinary co-ordination and
participation was essential. In particular, multi-disciplinary working could also
enhance medical assessment, law enforcement investigation and legal processes as
services (Mosqueda etal. 2004; Navarro etal. 2010). In terms of legal intervention,
specialist legal services were considered a positive response to managing and raising
awareness of elder abuse (Velasco 2000). Legal intervention was also found to be
signicant in the cessation of the abuse as perpetrators were held responsible (Jackson
and Hafemeister 2013). Having a multi-disciplinary response to nancial abuse was
considered particularly important as this form of abuse is the only category that is not
necessarily within the typical domain of health and the immediacy of the individual’s
body but involves other sectors (such as nancial institutions and social protection
departments). Aziz etal. (2000) examined the work of the Fiduciary Abuse Specialist
Team (FAST) in Los Angeles and found that the team’s work resulted in increased
awareness of nancial abuse as well as having optimum and speedy outcomes.
Jackson and Hafemeister (2013) interviewed adult protective service casework-
ers (N=71), older victims (N=51 and third party persons (N=35) to examine if a
change in living arrangements, the appointment of a guardian, continuing contact
with the abuser, perceptions of future risk and consequences for abusive individuals
were important in abuse continuation after case referral. Findings demonstrated that
continued living with the abuser and the absence of negative sanctions on the abuser
impacted prolonging the maltreatment.
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201
Reis and Nahmiash (1995) evaluated the multi-disciplinary team approach
(screening tool package, responsive intervention team) in Project Care for 218
abused older people demonstrating similar ndings to the studies above; however,
they also examined the implementation of a social capital approach through the
availability of a volunteer buddy system who worked with both the older people and
the perpetrator, a support group and a community level advocacy group. Findings
demonstrated that these approaches were both cost-effective and underpinned effec-
tive care management.
Similarly, the mobilization of community within a restorative justice framework
was applied as an alternative management model for elder abuse which involved a
skilled facilitator and focused on conict management and resolution (Groh and Linden
2011). While the project was judged successful and increased collaboration, highlight-
ing both general awareness and the older person’s voice and developing robust net-
works, it was noted that it involved a greater than anticipated amount of resources, time
and additional training and that it was only suitable for some cases of elder abuse (Groh
and Linden 2011; Stones 2004), thus constituting an option pathway within traditional
services (Linden 2006). Other challenges concerned the low volume of case referrals
and the difculty in recruiting ‘neutral’ family members to become involved.
Another descriptive study by Holkup etal. (2007) was conducted with native
American Indians facilitating responses within their own community. Findings
pointed to the importance of integrating a culturally compatible response model
which would be acceptable to the population being assisted.
Brandl etal. (2003) and Seaver (1997) examined the impact of support groups
(mainly for women) and found such groups could reduce the older person’s sense of
social isolation and provided communities of support. However, both studies
acknowledged the imperative of having a contextual understanding in case manage-
ment which included an appreciation of the inherent ethical dimensions of the abuse.
Several studies examined the role of education in knowledge transfer for profes-
sionals, with Gironda et al. (2010) identifying health care professionals’ limited
understanding of elder abuse management. Education initiatives focused on health
care assistants/aides (Hudson 1992; Radensky and Parikh 2008), nurse assistants/
aide students (Smith etal. 2010), nursing students (McGarry and Simpson 2007),
public health nurses and social workers (Day et al. 2010), social work students
(Corley etal. 2006), dentists (Harmer-Beem 2005), multi-disciplinary professionals
(dentistry, emergency medical technicians, health care interpreters and community
workers, coroners, medical examiners) and advanced training for Adult Protective
Services (Gironda etal. 2010; Teitelman and O’Neill 2000). Many of these pro-
grams indicated that, following specic educational interventions, there was
increased awareness and clarity around the topic (Hudson 1992, Radensky and
Parikh 2008), increased understanding of their individual disciplinary roles and
inter-professional collaboration (Day etal. 2010; Heath etal. 2002) and the inherent
ethical responsibilities of case management (McGarry and Simpson 2007). Other
ndings identied that mandatory reporting gures could be improved (Harmer-
Beem 2005, Radensky and Parikh 2008) as well as increasing condence in manag-
ing cases of sexual abuse (Teitelman and O’Neill 2000) and highlighting the
14 An Ecological Perspective onElder Abuse Interventions
202
importance of integrating elder abuse topic and case management content into edu-
cational programs (Corley etal. 2006).
Other educational programs targeted professionals outside health and social
care. For example, Proehl (2012) delivered an educational program to clergy, which
increased community awareness and strengthened networks, while also reducing
the fear of reporting to adult protective services. However, the sustainability of such
programs requires appropriate leadership in the community.
The majority of the research papers retrieved from the literature search, which
empirically evaluated interventions using an experimental design, were classied
under the mesosystem ecological level. A total of 25 interventions evaluated in 27
peer-reviewed research papers using an experimental research design were identi-
ed as pertaining to the mesosystem ecological level. These were divided into seven
different categories: support groups for older people including survivor groups
(n=2); interventions targeting perpetrator behavior (n=2); and interventions which
targeted caregivers, including informal carers (n=3), nurses and nursing assistants/
aides (n=6), physicians (n=5), rst responders (n=2) and other types of formal
healthcare professionals, such as dentists (n=5).
14.7.2 Support Groups forOlder People
Bowland etal. (2012) undertook a randomized controlled experiment evaluating the
efcacy of a spiritual therapeutic group intervention with older women survivors of
interpersonal violence (N=45). In this experiment, a signicant positive effect was
found for the intervention on the outcome measures of depressive symptoms, anxi-
ety and physical symptoms. These positive effects were maintained at a three-month
post-intervention follow-up.
Brownell and Heiser (2006) undertook a randomized controlled experiment eval-
uating the efcacy of a psycho-educational support group with older female victims
of family mistreatment (N=16). The outcomes measured in the assessment of inter-
vention efcacy included: locus of control, social support, depression, somatization
and guilt. No signicant effect was found for the intervention on any of the outcome
measures.
14.7.3 Interventions Targeting Perpetrator Behaviour
Campbell Reay and Browne (2002) undertook a non-randomized quasi-experiment
(pre and post-test) design to evaluate the efcacy of an education and anger man-
agement program among a sample of perpetrators of elder abuse (N= 19). The
authors reported a signicant effect for the training post-intervention and at 6weeks
follow-up for the outcome measures of strain, depression and anxiety. Furthermore,
A. Phelan and D. O’Donnell
203
a signicant effect was also found for the cost of care as well as conict tactics and
reductions in these measures were maintained at 6weeks follow-up.
Scogin etal. (1990) evaluated the evidence for the efcacy of a caregiver training
program targeting caregivers found to be abusive or at risk of abuse (N=95) using
a non-randomized control/intervention comparison design. The authors concluded
that cognitive behavioral training can reduce psychological distress and perceptions
of the cost of care among potential perpetrators of abuse.
14.7.4 Interventions Targeting Informal Caregivers
Drossel etal. (2011) employed a quasi-experimental (pre and post) design to evalu-
ate the evidence for the efcacy of an intervention providing dialectic behavior
therapy skills training to non-professional caregivers of people with dementia
(N=16). The authors found a positive effect for the intervention on psycho-social
adjustment, specically increased problem-focused coping, enhanced emotional
well-being and less fatigue.
Hébertetal. (2003) undertook a multi-center randomized controlled experiment
to evaluate the efcacy of a psycho-educative group program targeting caregivers of
people with dementia (N = 118). The outcome measures used by the authors to
evaluate efcacy included self-perceived health, care recipient’s disease and care-
giving issues. The authors found a signicant effect post-intervention for their
psycho- educative program targeting caregivers of people with dementia on the out-
come measures of reaction to and the frequency of behavioral problems of care-
recipients. No effect was found on more global outcome measures of stress,
psychological distress, burden and social support.
Phillips (2008) evaluated the efcacy of psycho-educative nursing intervention
using a randomized controlled experiment which measured intervention effect on
the frequency and intensity of physical and verbal/psychological aggression toward
older caregiving wives and daughters (N=83) by care recipients. The authors found
evidence which supported the efcacy of the intervention in reducing the verbal
aggression experienced by caregivers of older men. Furthermore, these caregivers
experienced signicantly less depression, anger and confusion following the inter-
vention. However, this effect was not found for caregivers of older women and the
intervention was found to have no signicant effect on the experience of physical
aggression, disruptive behavior and social function.
14 An Ecological Perspective onElder Abuse Interventions
204
14.7.5 Interventions Targeting Nurses andNursing Assistants/
Aides
Braun etal. (1997) evaluated a short-course educational program aiming to prevent
elder abuse that may arise within the nursing relationship as a result of professional
burnout, resource constraints or stress. They employed a quasi-experimental (pre
and post) design using a sample of nurses’ aides working in a nursing home
(N=105). Their study found a positive evaluation of the learning materials by the
participants with a signicant increase in job satisfaction post-intervention.
Désy and Prohaska (2008) described and evaluated the Geriatric Emergency
Nursing Education (GENE) course providing education and training on geriatric
nursing, which included a module on the identication, management and reporting
of elder abuse and neglect. They employed a quasi-experimental (pre and post)
design with a sample of emergency nurses (N=63) and found a positive effect for
the intervention on knowledge of geriatric concepts and self-rated ability to provide
care in a number of relevant areas including appropriate referral to protective
services.
Goodridge et al. (1997) evaluated a specic abuse prevention program which
was designed and developed by the Coalition of Advocates for the Rights of Inrm
Elderly (CARIE). They evaluated the efcacy of this program on a sample of nurs-
ing assistants (N=136) in a long-term care facility using a quasi-experimental (pre
and post) design. The program was positively evaluated by the nursing assistants
and the pre/post tests indicated a positive effect for the intervention in terms of the
sample’s attitudes towards older patients and a signicant decline in self-reported
nursing assistant-resident conict.
Hsieh etal. (2009) employed an experimental design incorporating a comparator
control group to evaluate the efcacy of an educational support group program for
geriatric caregivers. This case-control study recruited caregivers (N= 100) from
four nursing homes in southern Taiwan. The experiment found a signicant positive
effect in reducing psychological abusive behavior by caregivers and promoting
knowledge of geriatric care giving. However, no signicant effect was found for
reducing work stress.
Pillemer and Hudson (1993) evaluated a specic abuse prevention program
which was designed and developed by the Coalition of Advocates for the Rights of
Inrm Elderly (CARIE). They employed a quasi-experimental (pre-post) design
with a sample of nursing assistants (N= 114) randomly selected from 10 nursing
homes. The evaluation of the CARIE program found a signicant positive effect for
evaluations of the intervention as well as improvements on a number of indicators,
including reduced conict with and abuse of residents.
Teresi etal. (2013) evaluated an intervention which sought to reduce resident to
resident elder mistreatment in an institutional setting through awareness raising and
training of nursing staff in appropriate prevention and management strategies. They
employed a clustered randomized trial, randomized at facility level with matched
controls, targeting certied nursing assistants and measuring outcomes on residents
A. Phelan and D. O’Donnell
205
(N=1405) randomized into a control and intervention group. The authors found a
signicant positive effect for the intervention on knowledge and recognition of resi-
dent to resident elder mistreatment. Furthermore, there were signicantly increased
levels of reporting of mistreatment among the intervention group.
14.7.6 Interventions Targeting First Responders
Nusbaum etal. (2006) and Nusbaum et al. (2007) measured the effect of a work-
place education program on attitudes and behaviors of police and reghters
responding to a situation of potential elder abuse. The authors employed a quasi-
experimental (pre and post) design over three-time points to measure the effect of
an intervention which aimed to increase awareness and detection of neglect and
abuse of older people among police and reghters (N=101). The authors found no
signicant effect for their intervention and concluded by highlighting the difculty
of using educators external to an organization to drive attitudinal and behavioral
change.
Seamon etal. (1997) undertook a quasi-experiment (pre and post) to evaluate the
efcacy of a 45-min training video on improving the ability of pre-hospital emer-
gency medical service personnel (N=60) to identify and report suspected cases of
elder abuse. The outcomes measured in the experiment included identication of
elder abuse and neglect, willingness to report suspected cases, denitions of elder
abuse and neglect and mandatory reporting requirements. The authors found evi-
dence to support the efcacy of their educational video.
14.7.7 Interventions Targeting Physicians
Cooper etal. (2012) evaluated evidence for the efcacy of a short group educational
program on trainee psychiatrists (N=40) using a quasi-experimental (pre and post)
design undertaken at three-time points. The authors found evidence to support the
efcacy of the intervention in increasing recognition of abusive caregiving strate-
gies as well as knowledge of the management of elder abuse.
Famakinwa and Fabiny (2008) evaluated the efcacy of a small group teaching
session on the topic of caregiver stress delivered to medical residents (N=40) using
a quasi-experimental (pre and post) design. The authors reported that signicant
positive effect was found for the intervention on recognition of elder abuse and an
understanding of caregiver stress.
Jogerst and Ely (1997) undertook a case/control non-randomized comparison of
family practice residents in order to evaluate the efcacy of a home visit program,
14 An Ecological Perspective onElder Abuse Interventions
206
which was delivered as part of a geriatric rotation. The aim of the program was to
enable family practice residents to evaluate patients for elder abuse and capacity in
their homes. The authors reported a positive effect of the program on residents’ self-
rated ability to diagnose elder abuse and assess a patient’s home environment
post-intervention.
Shefet etal. (2007) evaluated the efcacy of a national domestic violence expe-
riential training program based on standardized patients to improve the knowledge,
skills and detection rates of primary care physicians (N=74). The program per-
tained to three areas of domestic violence, one of which was elder abuse. The
authors reported a positive signicant effect on the intervention in self-perceived
capabilities and overall case management of domestic violence among
participants.
Uva and Guttman (1996) evaluated the efcacy of a 50-min education session on
elder abuse with emergency medical residents (N=31) using a matched controlled
survey. The outcome measures used to assess efcacy pertained to knowledge of
elder abuse and self-rating of the intervention. The authors reported a signicant
positive effect for the intervention on elder abuse knowledge post-training and at
1-year follow-up.
14.7.8 Interventions Targeting Multidisciplinary Healthcare
Providers
McCauley etal. (2003) created and evaluated a multi-disciplinary continuing medi-
cal education videotape on interpersonal violence (ASSERT), which incorporated a
module on elder abuse. They employed a quasi-experimental (pre and post) design
with a sample of physicians (N = 120) and other healthcare providers including
nurses and social workers (N = 172). The authors found a signicant level of
improvement for knowledge and attitudes towards interpersonal violence and the
intervention was rated positively by the participants.
Mills etal. (2012) evaluated evidence for the efcacy of an education program
concerning elder investment fraud and nancial exploitation. The program targeted
a range of healthcare professionals (N=127), including physicians, nurses, social
workers, occupational therapists and physiotherapists. The outcomes measured to
assess efcacy included self-assessed ratings of the program as well as the imple-
mentation of program material into practice, specically the number of elder abuse
cases identied 6 months post the intervention. The authors reported a positive
effect for the intervention using summary descriptive statistics.
Using a randomized controlled trial Richardson et al. (2002) and Richardson
etal. (2004) evaluated the efcacy of attendance at a short educational course on
managing elder abuse with healthcare staff (N=64), including nurses, care assistants
A. Phelan and D. O’Donnell
207
and social workers. The authors reported a signicant positive effect for the inter-
vention on knowledge and management of abusive scenarios.
Sugita and Garrett (2012) evaluated the efcacy of an intervention to increase
knowledge and self-perceived likelihood to report elder abuse among oral health-
care providers (N= 103). They conducted a quasi-experiment (pre and post) and
reported post-intervention increases in awareness of reporting processes, knowledge
and awareness of elder abuse, knowledge of mandated reporter requirements and
increased recognition of elder abuse.
Vinton (1993) evaluated an elder abuse and neglect prevention education pro-
gram on a mixed sample of caregivers (N=107), which included homemakers, per-
sonal care aides, respite workers, case managers, administrators, nurses, social
workers and law enforcement ofcers. They undertook a quasi-experiment (pre and
post) and concluded that case managers showed the most improvement in their
knowledge of elder abuse law as well as the nature of elder abuse and the principles
that guide protective services.
14.7.9 Summary
What is clear from the review of the descriptive studies in the mesosystem is that
successful case management is dependent on having responses tailored to the case.
While some studies had small sample sizes, there was an impact in the initiatives
related to both case management and educational programs. In particular, case man-
agement demands good leadership and the effective collaboration of multi-
disciplinary teams. Community awareness is also important as well as the
involvement of community-level groups, such as faith groups and others to raise the
issue of elder abuse and introduce it into their members as a topic of concern. The
educational interventions within the descriptive studies highlighted the need to
spend time and reect on cases to effectively navigate their complexities. Educational
interventions were shown to increase case referrals and case efciency, while the
clarity of responsibilities (ethical, practice professional, mandatory reporting) were
enhanced, particularly when using case scenarios (Day et al. 2010; Heath et al.
2002) as a learning method. Educational programs were also evaluated as good
interventions for members of organized religion and faith communities and strength-
ened community social capital in responding to elder abuse.
Overall the level of evidence for the experimental research designs used to evalu-
ate the 25 interventions identied in this study and classied under the mesosystem
category was found to be weak (O’Donnell etal. 2015). The majority of the studies
were evaluated as being at risk of bias, with poor intervention implementation and
outcome measurement. None of the interventions which targeted support or survi-
vor groups for older people (n=2), perpetrators (n=2), physicians (n=5) or rst
responders (n=2) was found to have a high level of evidence quality to support
efcacy (O’Donnell etal. 2015).
14 An Ecological Perspective onElder Abuse Interventions
208
In relation to interventions which targeted informal caregivers (n=3), two were
found to have a good evidence base to support their efcacy (O’Donnell etal. 2015).
These interventions included a psycho-educative program targeting caregivers of
people with dementia using the outcome measures of reaction to and the frequency
of behavioral problems of care-recipients (Hébert etal. 2003). There was also high-
quality evidence to support the efcacy of a psycho-educative nursing intervention in
reducing the verbal aggression experienced by caregivers of oldermen as well as
reducing caregivers’ experiences of depression, anger and confusion (Phillips 2008).
One intervention which targeted nurses or nursing assistants/nurses’ aides were
found to have a strong evidence base to support efcacy (O’Donnell etal. 2015). A
very high rating was assigned to the quality of the evidence supporting an interven-
tion which sought to reduce resident to resident elder mistreatment in an institu-
tional setting through awareness raising and training of nursing staff in appropriate
prevention and management strategies (Teresi etal. 2013). Of the ve interventions
that targeted multi-disciplinary healthcare providers, the strongest evidence for the
efcacy of intervention was found for a short educational course on managing elder
abuse (Richardson etal. 2002, 2004).
14.8 Exosystem
The exosystem represents a step further from the immediate environment of the
older person and is constituted by various service levels, such as adult protective
services, the criminal justice service, the social welfare system, the political system
as well as educational and health systems. In total, 32 papers were categorized into
the exo-system. There were 28 papers categorized in this system related to descrip-
tive studies; 14 were related to evaluations of systems of service delivery, 9 related
to the criminal justice system and 5 belonged to systems process improvement.
There were four papers presenting three interventions which were classied under
the experimental studies.
14.8.1 Evaluation ofSystems ofService Delivery
In the evaluation of systems of service delivery, the development of adult protective
services in the United States had not received the same interest as other areas of
family violence (Dyer etal. 2005). Some of the papers reviewed presented a descrip-
tion of services rather than evaluation (Dyer etal. 2005; Kaye and Darling 2000;
Reingold 2006; Solomon and Reingold 2012) and supported a multi-disciplinary
and inter-setting collaboration (adult protective services, criminal justice system,
health care assessment) in responding to elder abuse. Within service descriptions,
Dyer etal. (2005) describes the activities of the adult protective services in case
management and considers the pathways available to respond to the individual
A. Phelan and D. O’Donnell
209
aspects of the older person’s abuse. The Weinberg Centre (Reingold 2006, Solomon
and Reingold 2012) offered a continuum of elder abuse intervention services such
as a toll free number for information, community based team, emergency center
assessment, a medical day program and pathways to return to community or place-
ment in long term accommodation comprised of apartments or residential care
admission. Kaye and Darling (2000) also provided a description of the state of
Oregon’s Attorney General’s task force to respond to nancial exploitation of older
people. This involved training for bank staff, an elder abuse prevention program
targeting older people, enhancing telephone safety and awareness of MOOCH lists
and their function.
Teaster and Wangmo (2010) reviewed 32 multi-disciplinary elder abuse local
coordinating councils on elder abuse in Kentucky. Findings pointed to the identi-
cation of appropriate services, awareness raising, training and advocacy, although
there was a lack of service standardization in policy documents and the authors
noted the need to have appropriate structural, human and nancial resources.
Different service models (crime victims approach versus social support) did not
demonstrate any advantage in terms of outcomes, however, having access to legal
and social supports was considered fundamental in tailoring responses to individual
cases (Brownell and Wolden 2002; Sengstock et al. 1991). In Ernst and Smith’s
(2012) study, the nancial cost of having a nurse-social worker team as opposed to
a lone social worker was not justied, while in another study, the intervention of
adult protective services in the United States was found to greatly increase the risk
of nursing home admission (Lachs etal. 2002). For people living with dementia, a
study in Cleveland demonstrated that having adult protective services working with
the Alzheimer’s Society increased cross-service collaboration but also emphasized
the need to understand each organizations’ roles and responsibilities as well as
developing successful communication channels (Anetzberger etal. 2000).
Tools and training to assist decision-making and reporting were also evident in
the literature. For people who have cognitive capacity challenges, Horning etal.
(2013) developed a decision-making ow chart to assist clinical staff’s management
of nancial abuse and to guide decisions on interventions needed, however, this was
not evaluated.
Informal community networks were seen to empower older people to assert
rights (Cripps 2001) while the need to have family centered therapy and mediation
to address relevant case issues both historical and current was recognized (Bergeron
2002; Wall and Spira 2012).
14.8.2 Criminal Justice System
Increasing knowledge and collaboration was considered important in relation to
elder abuse within the criminal justice system and the police service. Studies
described enhancing legislative responses to elder abuse, training for law enforce-
ment staff and having specialized case management processes (Heisler 2000). In
14 An Ecological Perspective onElder Abuse Interventions
210
reviewing the relationship between adult protective services and criminal justice
professionals, Blakely and Dolon (2001) found that collaboration with police was
helpful in case management, however, challenges were noted in relation to working
with victims’ assistants due to a lack of explicit disciplinary relationships.
Community awareness and professional knowledge of elder abuse statutes, particu-
larly related to mandatory reporting, was important and increased investigation
rates (Daly etal. 2003; Jogerst etal. 2003). However, mandatory reporting could
disempower the older person and negatively impact the clinician-older person rela-
tionship (Lai 2008; Rodriguez etal. 2006). Equally, while systems of guardianship
were framed to act in the older person’s best interests, there was potential for abuse
and safeguards need to be in place to ensure decisions made by the guardian are not
biased (Black 2008; Kohn 2006). Consequently, legislation needed to provide for
protective safeguards for older people in addition to sanctions for people who abuse
legislative powers such as guardianship. In an attempt to improve medical docu-
mentation for legal cases, Koin (2003) described the development of a bespoke
medical examination form which incorporated examination of cognition, consent,
pain assessment and case contexts. The examination form was developed for health
professionals who had special forensic training in elder abuse as well as other pro-
fessionals such as nurses, physicians and assault specialists.
14.8.3 Systems Process Improvement
System process improvement studies involved publication within which response
systems were examined within the context of serious case reviews of practice fail-
ures in responding to cases of abuse. In the United Kingdom, Cambridge et al.
(2011) review more than 6100 case referrals and concluded that having specially
trained adult safeguarding coordinators was shown to improve both process and
outcomes in case management in terms of more comprehensive investigations and
joint collaboration with other agencies (Cambridge etal. 2011). Noting the lack of
case standardization, a 2-day training program on decision making for choosing
appropriate elder abuse interventions and a data monitoring system was considered
as enabling case management consistency (Cambridge and Parkes 2004).
The nal study included in systems process improvements involved interviews
with ten members of safeguarding boards and four independent chairs of serious
case reviews (Manthorpe and Martineau 2012). Findings revealed that serious case
reviews contributed to organizational learning, however, there was a tension in the
conduct of the reviews between a no blame focus and potential negligence. Findings
pointed to the value of an independent chair, while also highlighting the need to
have a better underpinning legislative basis to improve information gathering and
process.
Three interventions which were evaluated using experimental research designs
were identied as pertaining to the exosystem ecological level (Davis and Medina-
A. Phelan and D. O’Donnell
211
Ariza 2001; Davis etal. 2001; Jogerst etal. 2004; Navarro etal. 2013). The three
interventions, which were described in four peer-reviewed articles, and classied at
the exosystem level were:
• a community level intervention aimed at reducing repeat incidences of elder
abuse through a public education program combined with targeted home visits
from law enforcement and social workers (Davis and Medina-Ariza 2001; Davis
etal. 2001);
• compulsory training for mandated reporters in the state of Iowa, USA (Jogerst
etal. 2004);
• an elder nancial abuse forensic centre providing multi-disciplinary consultation
for complex cases of elder nancial abuse (Navarro etal. 2013).
Two of the studies employed a case-control matched design (Jogerst etal. 2004,
Navarro etal. 2013) and the third study evaluated efcacy using a nested random-
ized controlled design (Davis and Medina-Ariza 2001, Davis etal. 2001).
14.8.4 Summary
Within the descriptive studies, it is difcult to determine the actual impact of inter-
ventions for those that simply described services without any rigorous evaluation.
While describing services gives information on bespoke interventions, there is a sub-
stantial gap in assessing how successful these interventions are in addressing elder
abuse within issues of economics, the acceptability of service responses, replicability,
outcomes and other criteria. Other studies which did apply evaluation methods iden-
tify advantages such as emphasizing the importance of community support, enhanced
inter-agency collaboration and networking, reduction of risk, availability of resources,
awareness raising, but also some limitations, such as a lack of standardization or a
lack of funding, dysfunctional inter-agency collaboration and a cost limitation in
comparison to other elder abuse service delivery models. One study (Lachs etal.
2002) pointed to the higher risk of nursing home placement for older people referred
to adult protective services. While this may place the older person in an environment
of ‘safety’, it is possible that this impacts the happiness of the older person, who may
have wanted to remain at home. Moreover, having robust, standardized systems in
place is important and these should have legislative foundations, as well as indepen-
dent chairs, which were seen as important in serious case reviews of abuse.
Overall the level of evidence found to support the experimental interventions
identied at this ecological systems level was reasonably high (O’Donnell etal.
2015). All three papers employed a control or comparator group in their experimen-
tal design. Two of the studies rated fairly well in relation to the strength of the evalu-
ation design in terms of risk of bias, intervention implementation and outcome
measurement (Davis and Medina-Ariza 2001; Davis et al. 2001; Navarro et al.
2013). Only one of the studies evaluated the cost-efciency of the intervention and
14 An Ecological Perspective onElder Abuse Interventions
212
discussed potential unanticipated or unintended outcomes (Davis and Medina-Ariza
2001, Davis etal. 2001).
Of the three studies, the strongest evidence for efcacy was found for a public
education program combined with home visitation (O’Donnell et al. 2015). The
authors concluded that the combination of education and home visits increased the
likelihood of reporting elder abuse (Davis and Medina-Ariza 2001, Davis etal. 2001).
14.9 Macrosystem
This system represents the culture within which people live and the values sub-
scribed to by a society, which are operationalized in legislation, policy, heritage and
identity. This system had the least amount of studies related to interventions in elder
abuse. Five were categorized under descriptive studies, while only one was included
under experimental studies.
Within the descriptive studies’ papers, two papers discuss legislation in the
United States. Connolly (2010) notes that a more facilitative approach to legal
redress is needed which includes having a multi-disciplinary advisory team, addi-
tional use of forensics and comprehensive evaluation reports. For people in nursing
homes, the Patient Protection and Affordable Care Act (US Statute2010) was con-
sidered to enhance care provision in nursing homes in the United States and further
safeguard residents (Hawes etal. 2012).
Following court based research with jurors and experts on the nancial abuse of
older people, Gibson and Greene (2013) argued that the system needed to enable
jurors to understand factors unique to such cases, such as the psychological context
of the abuse perpetration. It is argued that a using social framework testimony by
experts in nancial abuse can offer jurors information about the case to help them
interpret the evidence in context and without bias, particularly related to potential
ageist perceptions. Although the criminal justice route is one standard response for
older people who have been abused, the application of a restorative justice frame-
work has been argued as more appropriate, avoiding the adversarial environment of
courtrooms (Groh 2005).
While most of the publications focused on the legal system, one paper reports on
stafng and nance in detection and intervention services in Japan. Following a
survey of 927 municipalities, Nakanishi etal. (2013) noted the need for policymak-
ers to enhance elder abuse staff resources and nances for appropriate services to
protect older people.
One intervention was evaluated using an experimental research design was iden-
tied as pertaining to the macro-system ecological level (Leedahl and Ferraro
2007). The intervention was an educational program designed to effect change in
public attitudes and perception of elder abuse as it is reported in the media (Leedahl
and Ferraro 2007). The efcacy of the educational program was evaluated using a
randomized controlled trial design with a mixed age sample (N=60). The authors
A. Phelan and D. O’Donnell
213
found evidence to support the efcacy of education about elder abuse, in the form
of reading material, to effect positive change in perceptions of the importance of
elder abuse as a topic for media reporting.
14.9.1 Summary
There is a relative paucity of studies which examine interventions in elder abuse at
the level of the macro-system. In reviewing the ve descriptive studies, many consti-
tuted commentaries on process and most referred to the legal response system. While
the arguments are valid in terms of process, there is no account of how older people
themselves experience the legal system in elder abuse case management and how
such data could be used to improve the experience. Despite this, studies point to the
need to make the system itself more user-friendly while also addressing any bias in
jurors and making the unique features of elder abuse cases transparent. Groh (2005)
argues about using a restorative justice approach for elder abuse cases, however,
studies cited earlier in this review (Groh and Linden 2011) (Linden 2006) point to the
limitations in having restorative justice as an exclusive response system. The Japanese
study (Nakanishi etal. 2013) ndings point to the fundamental need to have a com-
prehensive and resourced adult protective service for older people who are abused.
For the experimental study categorized in the macro-system, ndings were con-
sidered to be undermined by the considerable risk of bias in the design due to the
lack of blinding of participants and evaluators (O’Donnell etal. 2015). Furthermore,
the quality of the intervention was considered to be weak due to the potential con-
founders such as the Hawthorn effect, the heterogeneity of a convenience sample,
poor outcome measurement and limited explanation of intervention (O’Donnell
etal. 2015).
14.10 Discussion
While there are many varying elder abuse interventions in the literature, their trans-
ferability may be inuenced by structural conditions in different countries. For
example, Du Mont et al. (2015) noted that in a review of hospital-based care
responses to elder abuse, 4 out of 5 came from the United States or Canada and sug-
gests that applicability within other jurisdictions may be limited.
The review indicated a scarcity of research papers which empirically evaluated
interventions targeting the micro-system level, i.e. the older person (n=5), while
there was still a relatively small number categorized under the descriptive studies
(n=13). The majority of the research papers retrieved were in the mesosystem 27,
which were descriptive studies and 25 which empirically evaluated interventions
using an experimental design; most targeted the relations between micro-system
14 An Ecological Perspective onElder Abuse Interventions
214
settings which contain the older person. For the exosystem, there was a dispropor-
tionate representation in the descriptive studies (n = 20) as opposed to only 3
interventions for experimental studies. Interventions targeting the macro-system
level only accounted for 6 studies; 5 being descriptive and only one focused on an
experimental study.
In reviewing the literature related to descriptive studies, it is difcult to evaluate
outcomes in papers which provide simple program descriptions without any formal
evaluation. In addition, other studies had small sample sizes, which can limit nd-
ings. Some interventions could also be demonstrated as having a neutral impact,
however, in general, studies acknowledged the need for skilled professionals who
have experience in the type of abuse, interagency collaboration and having responses
which are acceptable to the older person. Overall the quality of evidence for evaluat-
ing the efcacy of interventions described using an experimental research design
was poor (O’Donnell etal. 2015). Across the four intervention categories, the high-
est level of evidence was found to support the exosystem level interventions. While
some studies demonstrate success in intervention approaches, there is a paucity of
good quality evaluations, in terms of robust design, adequate outcome measurement
and clear transferability of the intervention. Evaluating the effectiveness of targeted
interventions is challenging due to the complexity of elder abuse and its associated
issues, such as self-determination, health challenges, the victim and/or perpetrator
dependencies, family and cultural values, lack of standard understandings, as well
as structural, policy and legislative gaps.
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A. Phelan (ed.), Advances in Elder Abuse Research, International Perspectives
on Aging 24, https://doi.org/10.1007/978-3-030-25093-5_15
Chapter 15
The Public Health Approach toElder
Abuse Prevention inEurope: Progress
andChallenges
YongjieYon, JaniceLam, JonathonPassmore, ManfredHuber,
andDineshSethi
15.1 Introduction
Abuse and neglect of older adults is a societal problem that exists in all countries
(Krug etal. 2002). The World Health Organization (WHO) denes 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.
(WHO 2002 p.3)
Furthermore, elder abuse can be categorized according to a number of character-
istics: type of abuse—psychological, physical, sexual, and nancial abuse and
neglect; type of abuser—family members, informal and formal caregiver, or
acquaintance; and type of settings—community and institution (Gorbien and
Eisenstein 2005; Krug etal. 2002; Sethi etal. 2011; WHO 2002).
This book chapter describes the progress and challenges made with addressing
elder abuse. It is presented in ve sections: (1) Introduction to the problem 2) What
is the extent of the problem and has the issue of elder abuse been made more ‘visi-
ble’; (3) What are the risk factors for elder abuse (4) What works for prevention and
are countries implementing prevention programs 5) Are countries developing
national action plans to coordinate action against elder abuse?
Y. Yon (*) · J. Lam · J. Passmore · M. Huber · D. Sethi
World Health Organization Regional Ofce for Europe, Copenhagen, Denmark
e-mail: yony@who.int
224
15.2 Why Is Elder Abuse SoImportant?
It was estimated that 5589 older adults aged 60years and over died by homicide in
the WHO European Region in 20161 (WHO 2016a). However, deaths only represent
the tip of the iceberg because for every death there may be many of hospital admis-
sions and thousands of unreported cases of elder abuse. It is estimated that 15.4% of
older adults living in the community and up to 33.4% of older adults residing in the
institutions experienced some form of abuse in the past year (Yon etal. 2017, 2018).
Elder abuse is both a human rights and a major public health problem due to its seri-
ous health consequences for the victims, including the increased risk of morbidity,
hospital admission, institutionalization and mortality as well as its negative impact
on families and society at large (Lachs etal. 1998; Dong and Wang 2016). Despite
its scope and severity, elder abuse remains a largely neglected public health priority
in comparison to other types of violence.
By 2030, there will be approximately 250million adults aged 60years and over
in the WHO European Region (United Nations Department of Economic and Social
Affairs 2017). If the rates of elder abuse were to continue, the potential increase in
the number of older adults in the community and in institutions who are subjected
to abuse and neglect will be enormous. Hence, urgent action is required in the pre-
vention and responses to elder abuse (Sethi etal. 2011).
15.3 Global andEuropean Calls forAction toPrevent Elder
Abuse Prevention
To ensure that every older person’s right to health and well-being is protected
against violence and other forms of adversity, civil societies have called for the
establishment of the United Nations (UN) Convention on the Rights of Older Adults
to protect and promote the rights of older persons (HelpAge International 2012). By
establishing legal standards to address ageist attitudes and behavior, the Convention
is expected to enhance accountability of Member States’ obligation to older adults
(HelpAge International 2012).
The 2030 Agenda for Sustainable Development seeks to realize human rights of
all. Ageing is a cross-cutting measure impacted by many of the Sustainable
Development Goals (SDGs) where the prevention of elder abuse is included promi-
nently in the SDGs with target 16.1 calling for signicant reduction in all forms of
violence and related death rates and several more goals focusing on risk factors,
including poverty eradication (goal 1), good health (goal 3), gender equality (goal
5), economic growth and decent work (goal 8), reduced inequalities (goal 10), sus-
tainable cities (goal 11), and just and safe communities (goal 16) (UN 2017). The
2030 Agenda emphasizes a life-course approach to ageing while protecting and
promoting the rights of older people (UN 2017).
1 The WHO European Region consists of 53 Member States.
Y. Yon et al.
225
There have been signicant global and regional policy developments on elder
abuse prevention including a national multi-sectorial approach in the WHO Global
plan of action to strengthen the role of the health system to address interpersonal
violence, in particular against women and girls (WHO 2016b). Furthermore, the
WHO global strategy and action plan on ageing and health (2016–2020) provides
a roadmap to healthy ageing which calls for key actions in the areas of health sys-
tems, age-friendly environments, better long-term care as well as improvements in
measurement, monitoring and research (WHO 2016c).
Similarly, preventing elder abuse is one of the supporting interventions of the
WHO strategy and action plan for healthy ageing in Europe (2012–2020). It calls
for actions to (1) draw up national policies and plans for preventing elder abuse; (2)
improve the evidence base for elder abuse and strengthen capacity for research on
effective interventions; (3) build capacity and exchange leading practices across
sectors for protection and prevention; (4) raise awareness and target investments on
preventing elder abuse; and (5) improve the quality of services in the community
and in institutions in order to ensure that quality regulations, standards, protocols
and guidelines are in place for preventing elder abuse (WHO 2012).
15.4 The Public Health Approach toPreventing
andResponding toElder Abuse
Successful responses and prevention of elder abuse involve an iterative four-step
public health approach (Fig.15.1). This evidence-informed approach considers the
epidemiology and extent of the problem, its risk and protective factors, and the evi-
dence base of what works to develop a model to design, implement, evaluate and
monitor interventions and scaling up with a widespread implementation of preven-
tion (Holder etal. 2001). The next sections follow this model.
15.5 What Is theExtent oftheProblem andHas Elder Abuse
Become More “Visible”?
The foundation of an effective public health response lies in the collection of reli-
able data. Given the hidden forms of elder abuse, gathering comprehensive data on
the problem requires the use of multiple information systems, including vital regis-
tration, hospital admissions, and population surveys. At present, routine data collec-
tion on elder abuse are limited due to lack of record keeping by health, police, and
social service ofcials.
15 The Public Health Approach toElder Abuse Prevention inEurope: Progress…
226
15.6 Mortality Data forHomicide Among Older Adults
Although there are variations in data quality due to a discrepancy in the coding
practices and inaccurate classication of mortality data on assaults and interper-
sonal violence, nevertheless, vital registration data on mortality are widely available
across countries in the Region and may be used as a proxy for deaths from elder
abuse, especially in the absence of more direct information. There is a paucity of
research in this area, though the European report on preventing elder maltreatment
estimated that about 30% of these homicide deaths may be attributable to abuse
(Sethi etal. 2011). Based on the WHO Global Health Estimates, there were 5589
homicides in older adults aged 60years and over in 2016, and the proportion of total
deaths is higher for men (57.4%) than for women (42.6%), except for older adults
aged 70years and over where there are more women than men due to their longer
life expectancies (WHO 2016a). There are gender sub-regional differences in homi-
cide rates in the Region. For instance, homicide rates in males 60years and over are
higher than females: 1.9 times higher in Commonwealth of Independent States
(CIS) countries and 1.5 times higher in the European Union (EU) countries.
Data from the European Detailed Mortality Database (Fig. 15.2) highlights a
consistent decline in homicide rates since mid-2000s for older adults aged 65years
and over. Trend data from 2004 to 2014 suggest that the homicide mortality rates of
older adults in the Region has decreased by 60% (4.55–1.82 per 100,000) over this
10-year period. While this is a welcome success, homicide rates in CIS countries
(5.4 per 100,000) are 7.3 times higher than in the EU countries (0.74 per 100,000)
Fig. 15.1 A public health approach to preventing abuse. (Source: WHO 2013)
Y. Yon et al.
1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013
noitalupop000,001rep+56nietaredicimoH
Year
Fig. 15.2 Homicide rate in 65+ years per 100,000 population in the WHO European Region
(1983–2014)– 5year moving average. (Source: WHO European Mortality Database 2016d)
Fig. 15.3 Homicide rates per 100,000 older adults 65+ in the WHO European Region (average for
2012–2016 or last available 5 years). Excluded in the gure are countries with populations less
than 200,000 population: Andorra, Monaco, and San Marino. Data was unavailable for Montenegro.
(Source: WHO European Mortality Database 2016d)
228
in 2014 (WHO European Mortality Database 2016d). Nevertheless, the rate of
decline in the CIS countries is faster and rates in the Region are converging.
There are large inequalities in homicide rates within the Region. When country-
level data are compared using 5-year averages in standardized death rates (SDR)
from homicide in 65+ older adults (Fig.15.3), a 24-fold difference is seen between
the country with the highest rate and one of those with the lowest (WHO European
Mortality Database 2016d).
15.7 Hospital Admission Data onAssaults AmongOlder
Adults
Hospital admission rates due to assault are a useful source of information to pro-
vide additional insight into elder abuse. However, detailed hospital data are not
routinely collected or available in a number of countries in the Region. Data
disaggregated by age are shown for seven countries with hospital admission data
for assaults (ICD-10 codes X85-Y09) (WHO European Mortality Database
2016d). Figure 15.4 shows age- specic hospital admission rate from assaults
indicating wide variation by age groups and between countries. In general,
admission rates are higher with increasing age. Injuries such as fractures, bruises,
head injuries and lacerations can be the result of assaults and falls due through
elder abuse (Lachs and Pillemer 2004). The lowest values are reported in Finland
and the highest in Czechia. However, results are difcult to compare across coun-
tries because of varying clinical practice and in recording and coding procedures.
Data quality issues, such as completeness and accuracy of coding of assaults as
well as variations in health-system infrastructure and access to services greatly
limit cross-country comparability.
15.8 Population Surveys ofElder Abuse
Surveys are an essential component of the public health approach to help under-
stand the true magnitude of elder abuse and its associated risk factors (Sethi etal.
2011). In particular, population surveys currently provide the only method to iden-
tify elder abuse that is not captured by vital registration (i.e. homicide data) and
hospital admissions (i.e. morbidity data). Survey data can be self-reported from
older adults (i.e. victims) or informant (e.g. health professional, in the institutional
settings) and is not without its own biases.
Y. Yon et al.
229
The WHO 2014 Global status report on violence prevention described the extent
of the problem of interpersonal violence and documented which country are collect-
ing data on violence. The report also assessed the status of program, policy and
legislative measures to prevent violence, in its place evaluated the availability of
healthcare, social and legal services for victims and identied gaps in interpersonal
violence prevention to stimulate national action. Of the 41 out of 53 participating
Member States, 40% (n = 16) of countries reported having a national survey to
assess elder abuse (WHO 2014a).
In addition, a recent meta-analysis found that one in six older adults (15.4%)
experienced elder abuse in community settings in the Region in the past year. Both
women and men are as likely to experience abuse (Yon etal. 2017). The lack of
gender difference in elder abuse is consistent with research on intimate partner
violence and is supported by both systematic review and meta-analysis (Archer
2000, 2002; Anderson 2005). Despite signicant awareness of elder abuse in insti-
tutional settings, there have been limited studies to examine the prevalence of elder
abuse in this setting.
A recent meta-analysis study suggests that rates of abuse are high in institutions
(Table15.1). Results show that staff-to-resident abuse in the past year is as high as
33% in the institution with 3 out of 5 nursing staff admitting to committing some
form of abuse in the past year (Yon etal. 2018). Older residents are at highest risk
for psychological (33.4%), physical (14.1%), nancial (13.8%) abuse, followed by
neglect (11.6%), and sexual (1.9%) abuse (Yon etal. 2018).
0
0.
5
1
1.
5
2
2.5
Croaa Czechia Finland Lithuania Malta SloveniaSwitzerland
60-6465-6970-7475-7980-84 85+
Fig. 15.4 Age-specic hospital admission rates for assaults on elder adults 60+ in select European
countries. (Source: WHO European Mortality Database 2016d)
15 The Public Health Approach toElder Abuse Prevention inEurope: Progress…
230
15.9 What Are theRisk andProtective Factors forElder
Abuse?
Abuse and neglect of older adults are a consequence of a complex interaction
between many risk and protective factors that operate at the individual, relationship,
community and societal levels (Krug etal. 2002). The ecological model is a useful
framework to describe these risk and protective factors to promote better under-
standing and implementation of interventions at the different levels (Schiamberg
and Gans 2008; Sethi etal. 2011). At the individual level, strong evidence indicates
that having dementia and other disability that creates dependence on carers is a risk
factor for being a victim of elder abuse. In the community, perpetration is most often
carried out by caregivers who are partners, offspring, or other relatives or carers. For
perpetrators, having a history of a mental illness especially depression, a previous
history of violence or drug or alcohol dependence are risk factors for perpetrating
abuse and neglect of older relatives in their care (Sethi etal. 2011). At the relation-
ship level, risk factors that increase the chances of perpetration includes dependence
on the perpetrator, living in the same household, and if the perpetrator is emotion-
ally or nancially dependent on the older relative, particularly if due to substance
dependence (Pillemer etal. 2016). At the community level, key risk factors include
living in isolation without community support networks and where there is ready
access to alcohol and drugs. Living in a society where violence is condoned, where
there is gender and income inequality and where there is ageism increase the risks
of elder abuse at the societal level. For example, living in socioeconomically
deprived environments are often associated with a number of risk factors associated
with elder abuse such as availability of alcohol and drugs (Dong and Wang 2016).
Older people who are living in institutional care are at increased risk when there are
inadequate regulatory frameworks and checks, poor staff training, insufcient sup-
port of staff, inadequate resources, an ethos that does not put care rst, institutions
Table 15.1 Reports of the prevalence of elder abuse in community and institutional settings
categorized by type
Elder abuse in community
settings (Yon etal. 2017)
Elder abuse in institutional
settings (Yon etal. 2018)
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%
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%
Y. Yon et al.
231
where violence is tolerated, and if residents are infrequently visited by relatives.
Perpetration may be carried out by health and care workers or by visitors (Drennan
etal. 2012; McDonald etal. 2012).
Conversely, there are also protective factors which should be encouraged. These
include community connectedness and positive life experiences. In care homes,
being frequently visited by relatives and friends appears to be protective. The inter-
generational effects of previous exposure to violence may also have some impact
and needs to be better understood. There is need for greater research to better under-
stand both risk and protective factors (Sethi etal. 2011).
15.10 Are Countries Implementing Prevention Programs?
A public health approach informed by evidence-based interventions is imperative to
implement relevant elder abuse prevention programs. Despite limited research on
effective interventions for elder abuse prevention compared to other types of domes-
tic violence, a number of promising interventions have been put into place across
the Region and elsewhere (Pillemer etal. 2016; Ploeg etal. 2009).
Public and professional information campaigns have been shown to increase
awareness of abuse which could lead to early detection and response in addressing
elder abuse. In addition, providing support to caregivers has been associated with a
reduction in caregiver burden, stress and depression (Pillemer etal. 2016; Ploeg
etal. 2009; Fearing etal. 2017). Figure15.5 highlights the proportion of countries
implementing larger scale programs to prevent elder abuse. Of the 41 countries that
responded to the 2014 Global status report on violence prevention, caregiver sup-
port programs has been reportedly implemented by half of the countries (51%;
n= 21) surveyed; however, public (27%; n=11) and professional (37%; n = 15)
awareness campaigns as well as residential care policies (39%, n=16) are still not
widespread (WHO 2014a, b). Overall, larger-scale implementation of elder abuse
prevention programs is more common in EU countries than in the CIS (Fig.15.6).
Since the adoption of the WHO strategy and action plan for healthy ageing in
Europe (2012–2020) WHO Europe is conducting a preliminary review to assess the
degree of development and implementation of policies including supporting interven-
tions associated with elder abuse prevention. To assess the progress, a review was
conducted on the national progress reports on policies for ageing societies submitted
to the United Economic Commission for Europe (UNECE 2017). A total of 44 reports
from Member States were submitted as part of the third cycle of the implementation
of the Madrid International Plan of Action on Ageing Regional Implementation
Strategy. Of these reports, 42 fall within the WHO European region and 41 reports
were assessed and analyzed. Activities on elder abuse prevention were described in
the majority of the reports (63%; n=26). While ndings from this review are prelimi-
nary, the results suggest that the public and policy-makers are increasingly concerned
about the problem.
15 The Public Health Approach toElder Abuse Prevention inEurope: Progress…
232
The provision of health and social services are essential for the prevention, detec-
tion and response to elder abuse (WHO 2016e). Hence, strengthening the health and
welfare systems and service provision for person-centered care can help reduce the
recurrence of elder abuse, prevent new cases, and improve physical and mental
health outcomes. The 2014 Global status report on violence prevention also assessed
0% 10% 20% 30% 40% 50%
60%
CIS
EU
WH
O EURO
Residenal care policies and procedures Caregiver support programs
Public informaon campaigns Professional awareness campaigns
Types of large scale violence prevention programs
Fig. 15.6 Large scale elder abuse prevention programs in the WHO European region and sub-
regions (% of countries). (Source: WHO 2014b)
0% 10%20% 30%40% 50
%60%
Public information campaigns
Professional awareness campa
igns
Residential care policies
Caregiver support programmes
% of countries with larger scale violence prevention
programs addressing elder abuse
Fig. 15.5 Proportion of countries in the WHO European Region implementing violence-
prevention programs on a larger scale to address elder abuse. (Source: WHO 2014b)
Y. Yon et al.
233
and evaluated the availability of health, social and legal services for the victims of
violence, including elder abuse (WHO 2014a). A sensitive response to the detection
of elder abuse is important to prevent further harm to the victims. For the Region,
adult protective services have not been implemented on a large scale which indi-
cates that the cases of abuse among older adults may remain hidden from adult
protective services. About 66% (n=27) of the countries have adult protective ser-
vices across the Region, however, only 41% (n=17) of the countries have imple-
mented these systematically on a large scale (WHO 2014b).
While there are many risk factors that lead to increased risk for sexual violence
and intimate partner abuse (Ramsey-Klawsnik 1991, 2004), health systems play a
crucial role in the multi-sectorial response to provide access to quality, comprehen-
sive services for survivors. Although it is unclear whether specialized services are
indeed available for older adults that are sensitive to their needs, nevertheless, about
85% (n=35) of the countries have services for victims of intimate partner and sex-
ual violence provided by health care providers across the Region and about 60%
(n=24) have implemented the services on a large scale. The provision of medico-
legal services is important for victims of sexual violence to ensure their protection.
Health-care providers should be trained to ensure they have a good understanding of
their country’s jurisdictions in reporting and responding to cases of sexual abuse.
Almost all of the countries (98%, n=40) in the Region have medico-legal services
for victims; 73% (n = 30) of countries have it systematically on a large scale.
Income-level inequalities between countries in the Region exist for implementing
medico-legal services for the victims, with 76% (n=19) of High Income Countries
(HICs) and 69% (n=11) of Low- and Middle- Income Countries (LMICs) reporting
provision of these services on a large scale (WHO 2014b).
Poor mental health and psychiatric illnesses are both a risk factor and conse-
quence of elder abuse (Cooper and Livingston 2014). Mental health services for
victims of violence in all age groups exist in 92% (n=38) of countries in the Region;
66% (n=27) have implemented them systematically on a large scale. There is a
large inequality in the provision of mental health services for victims of violence.
By income grouping, 72% (n=18) of HICs and 56% (n=9) of LMICs have mental
health services implemented on a large scale (WHO 2014b).
15.11 Are Countries Developing National Action Plans
toCoordinate Action AgainstElder Abuse?
The key message to policy-makers and members of civil society is that elder abuse
is wide-spread but not inevitable and can be prevented by taking a multi-sectorial
and public health approach. Developing an action plan is an important step toward
effective and coordinated approach to elder abuse prevention. In particular, an
action plan denes a framework for a comprehensive, systematic, multi-sectorial
and multidisciplinary approach to prevention at all levels – local, regional, national
and international (Schopper etal. 2006).
15 The Public Health Approach toElder Abuse Prevention inEurope: Progress…
234
Findings from the 2014 Global status report on violence prevention indicates that
53% (n=22) of countries in the Region have a national or subnational action plan for
elder abuse prevention (WHO 2014a, b). However, to establish realistic action plans
with specic quantied targets, timelines and monitoring strategies as well as good
epidemiological data are needed. Of the countries that have developed an action plan
for elder abuse prevention, over 45% have survey data (WHO 2014a, b). In other
words, the majority of the actions in countries to date have not been informed by
survey data. It is important that countries strengthen the collection of good epidemio-
logical data to inform the development of realistic national prevention action plans
and set quantied targets and timelines to monitor implementation (WHO 2014b).
Overall, country investment in violence prevention does not appear to match the
magnitude of the problem of elder abuse. Compared to the case of a specic action
plan on elder abuse prevention, there have been greater country investments in other
action plans in the Region: child maltreatment (78%), youth violence (63%), inter-
personal violence (51%), intimate-partner violence (85%), and sexual violence
(76%). While some of these action plans may be related to violence against older
adults, there remains a lack of specic attention and investment to elder abuse pre-
vention. Given the complexity and cross-sectorial nature of preventing and respond-
ing to elder abuse, a regular information exchange is needed to access, oversee and
coordinate prevention activities (Lachs and Pillemer 2004; Navarro etal. 2010). In
addition, responding to the complex cases of elder abuse involves a multidisci-
plinary team that utilizes different sectors and disciplines to investigate, referral and
resolve cases. Yet, health and social services are often fragmented and underfunded.
Multidisciplinary teams have been identied as an important best practice in
responding to elder abuse (Wolf and Pillemer 1994) and research indicated that hav-
ing access to professionals and experts in social services, criminal justice, and
health care elds can lead to increased criminal prosecution as well as access to
victim services (Navarro etal. 2013). Currently, only 78% (n= 32) of countries
surveyed have an information exchange system in place, but the comprehensiveness
of its coverage across all age segments is unclear (WHO 2014b).
Given the devastating impact of elder abuse, protecting older adults from abuse
and neglect is considered a core function of governance for public health. In addi-
tion to action plans, governments have an important role to enact and enforce legis-
lation to prevent elder abuse and protect the rights of older adults. Results from the
2014 Global status report on violence prevention found that 90% of 41 reporting
countries in the Region have laws relevant to violence; however, only 71% (n=29)
are directly related to addressing elder abuse and 59% (n=24) relating to address-
ing elder abuse in institutions. Enforcing laws to prevent elder abuse is also inade-
quate as only 41% (n=17) of countries reported enforcing laws to prevent elder
abuse in community settings and 29% (n = 12) in institutional settings (WHO
2014b). Overall, this level of reporting is inadequate which undermines the protec-
tion and promotion of the rights of older people. This is especially true with 32% of
HICs compared to 25% of LMICs in enforcing legislation against elder abuse in the
institutional settings.
Y. Yon et al.
235
15.12 Conclusion: TheWay Forward
Preventing elder abuse in Europe requires a stronger policy response and meaning-
ful resources to address this growing public health priority. Elder abuse has not
received the attention it should have, and only half the countries report having
national action plans. Moreover, over half of elder abuse prevention action plans
were developed without being informed by a population-based survey. Fewer coun-
tries report laws to prevent elder abuse in community and/or institutional settings
than for other areas of violence prevention. Such fragmentation is not surprising
since violence prevention activities including elder abuse are often spread across
multiple agencies, often without a lead agency identied for accountability and
monitoring purposes (WHO 2014b). Policies and national action plans for the pre-
vention of elder abuse need to be given at least as much attention as other types of
domestic violence where over 90% of countries have action plans.
A number of countries are investing in prevention, but not at a level commensu-
rate to the scale and severity of the problem. As such, a series of integrated actions
in accordance with international directives, adopted by Member States need to be
undertaken. Governments, municipal authorities, international agencies, Non
Governmental Organizations, practitioners, and other stakeholders need to address
the social injustice and inequity caused by the abuse and neglect of older people.
They need to consider the following actions:
1. Develop and implement national policies and plans for preventing elder abuse.
2. Take action to improve data on and surveillance of elder abuse.
3. Evaluative research on prevention programming needs to be undertaken as a
priority.
4. Response for victims need to be strengthened.
5. Address inequity by strengthening the prevention and response to elder abuse.
6. Build capacity across the sectors and promote intersectoral collaboration.
7. Raise awareness and target investment for preventing elder abuse.
8. Invest in protective factors across the life-course approach to promote intergen-
erational cohesion.
9. Enhance governance structures to improve the ethical standards and quality of
services in the community and in institutions.
This chapter highlights the public health problem of elder abuse and its likeli-
hood to increase given the rapidly ageing population in the European Region. It
advocates a public health approach to this problem, which is likely to grow unless
urgent action is taken. Even though homicides rates among older adults have
declined by 60% between 2004 and 2014, population-based surveys show that the
prevalence of abuse in the community and in institutions remains high. Overall, this
neglected public health priority requires countries to signicantly improve their
policy and programmatic response which has been inadequate to date.
The views expressed by authors and editors do not necessarily represent the
decisions or the stated policy of the World Health Organization.
15 The Public Health Approach toElder Abuse Prevention inEurope: Progress…
236
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A. Phelan (ed.), Advances in Elder Abuse Research, International Perspectives
on Aging 24, https://doi.org/10.1007/978-3-030-25093-5_16
Chapter 16
Human Rights andElder Abuse: TheCase
Example ofSerbia
NatasaTodorovic andMilutinVracevic
Elder abuse is a complex problem cross-cutting through social sphere, public health
and other distinct areas and it is a violation of human rights. The effects of elder
abuse can be dramatic not just for the older person experiencing abuse and her or his
immediate surroundings but also for society at large.
The phenomenon of demographic ageing has over the past 20years highlighted
the severity and seriousness of elder abuse, a problem that has for decades been
quietly overlooked (Krug etal. 2002). Despite the attention that it has now garnered,
elder abuse demands additional efforts in at least three different directions: further
research into the phenomenon as to better understand its scope as well as its differ-
ent aspects, raising public awareness on the phenomenon, as well as better preven-
tion and better regulatory frameworks. Based on these three directions, the Red
Cross of Serbia’s engagement with the phenomenon of elder abuse has also been
developed in three distinct branches.
16.1 Background Situation inSerbia
The data and the estimations of the Statistical Ofce of the Republic of Serbia for
2016 put the Serbian population at 7,058,322 whereas people over 65years com-
prised 19% of the total population. In the population over 65years, 57.5% were
female in 2016. With median age of 42.88years and the ageing index of 139.5, the
Serbian population is one of the oldest in the world. Additionally, the population
growth quotient was calculated at −5.3% for 2017, demonstrating the continuing
trend of depopulation in Serbia (Statistical Ofce of the Republic of Serbia 2017).
N. Todorovic (*) · M. Vracevic
Red Cross of Serbia, Belgrade, Serbia
e-mail: natasa@redcross.org.rs
240
For male children born in the 2014–2016 period, life expectancy was 73.01years
and 77.98years for female children born in the same period (Statistical Ofce of the
Republic of Serbia 2017). The longer life expectancy for women has its drawbacks
as it may lead to more years spent in worsened health. Also due to gender inequali-
ties during the active years, women are often faced with less favorable material
status in their older age and thus more likely to experience poverty. The statistics
show that in the over 65years population, the risk of poverty is signicantly higher
for women than for men (22% vs. 15.2%) (Babovic etal. 2018).
According to the projections by the Statistical Ofce of the Republic of Serbia,
older people’s proportion in the total population will continue to grow, especially
women over 80years and by 2041 the proportion of persons older than 65years is
expected to increase from 17% to 24%, while the rate of dependency of older people
during the projection period is expected to increase from 25% to 39% (Statistical
Ofce of the Republic of Serbia 2017).
16.2 Data andResearch
When the Red Cross in Serbia started engaging with this problem some 15years
ago, there was only one available Serbian study on elder abuse. Consequently, it was
clear that more research was needed to establish the prevalence of this phenomenon
in Serbia. In addition, it was important to explore the regulatory and institutional
framework in Serbia, examine existing policies and mechanisms to prevent and
respond to elder abuse and establish to what extent the system is effective in protect-
ing the human rights of older people.
According to the data published by the Republic Institute for Social Protection
and collected through the network of Centres for Social Welfare in 2016, the num-
ber of reported cases of domestic violence and intimate partner violence was 23,218.
Out of this number, 3018 were reported cases of elder abuse in family context,
representing a 13% share. This is a noticeable increase in the number of reported
cases of domestic violence in comparison with data from 2010 where the total num-
ber of reported cases was 8481 and the number of elder abuse cases was 1056–
12.45% of all reported cases (Republicki Zavod za Socijalnu Zastitu 2017a, b, c;
Republicki Zavod za Socijalnu Zastitu 2011).
Despite the increase in the number of reported cases of domestic abuse and elder
domestic abuse among them, this is still a small number in comparison with the
prevalence of elder abuse in Serbia established through research and which is in line
with the data from other European Countries as well as global data. This ts the
pattern of elder abuse being substantially underreported (World Health Organization
2008).
The Red Cross of Serbia has undertaken three research studies on elder abuse
and two other studies that have focused on older people in Serbia. The rst elder
abuse study, ‘Elder abuse: a study of violence in family context’ (Petrusic etal.
2012) is based on research of the legal framework and challenges related to reporting
N. Todorovic and M. Vracevic
241
abuse, processing the data related to these cases and managing the cases themselves.
The second study ‘Introduction to ageing and human rights of older people in
Serbia’ (Petrusic etal. 2015) is a pilot research study on nancial elder abuse, the
rst of its kind done in Serbia. The third study, ‘Well-kept family secret: elder
abuse’ (Jankovic etal. 2015) has looked into prevalence of elder abuse in Serbia.
‘Elder abuse: a study of violence in family context’, published (Petrusic etal.
2012) in February 2012, had two parts. The report provided an overview of the
existing legal framework in Serbia related to protection from violence in family
context. In addition, this report analysed selected cases of elder abuse targeting
multiple persons. Findings identied key problems in the management of elder
abuse by public institutions related to the provision of psychosocial support and
legal protection to older persons experiencing abuse, assessing whether cooperation
and coordination between different public institutions has existed and to what extent
such collaboration was effective.
The study analysed the data on violence in the family context provided by
Centres for Social Welfare and police administration from the second and third larg-
est cities in Serbia, Nis and Novi Sad. Elder abuse cases were selected from those
reported in these two cities and the analysis looked at how many older people were
targeted, where the abuse and violence took place, who the perpetrators were, what
was the method of collecting the data on the case as well as examining how much
and in what ways the institutions cooperated and coordinated their work related to
the cases.
Among the processed cases of family violence, approximately 10% targeted
older family members. More than 75% of older persons experiencing violence in
their families were female. The average age of the older person experiencing vio-
lence in the family context was over 70years. As for the perpetrators, the vast
majority (more than 90%) were male and most frequently children or grandchildren
of the victims (Petrusic etal. 2012).
When considering the catalyst to the case being reported to public institutions,
physical violence was identied as the most common reason whereas psychological
violence was rarely formally reported. It could be argued that the tolerance thresh-
old for psychological violence is very high for older persons and that this form of
violence is not considered to be substantial enough to generate a formal report to
services. This suggests that psychological violence needs to be dened precisely, in
order for it to be better identied. Psychological violence most frequently takes the
form of threats of physical harm, including threats to kill as well as verbal abuse.
In reviewing cases, a number of problems were identied in the case manage-
ment which include the following:
• There is no established and unied way and form through which to regularly and
systematically record, document and process cases of violence in family context
that would ensure collection of data related to perpetrators and victims of vio-
lence, the characteristics of violence, the reaction of public institutions, the intro-
duced measures to support the victims and punish the perpetrators etc.
16 Human Rights andElder Abuse: TheCase Example ofSerbia
242
• There is no regular practice of exchanging information between relevant public
institutions and organisations on violence in family context, including the vio-
lence against older persons, which particularly minimises the capacity of persons
surviving violence to exercise their right to efcient and effective protection
from violence.
• It is not established who should be responsible for the case management and
what the procedure should be to ensure that older people targeted by violence in
family context obtain a free of charge medical certicate based on medical or
forensic medicine examination, as well as adequate healthcare, including psy-
chological support and therapy when needed. This certicate establishes the case
and contains relevant evidence that can be used in the court of law
• There are no specic services of social welfare developed for older persons who
have survived violence in family context; this would include therapy and reha-
bilitation in line with their needs and living circumstances.
• There is no provision for older people surviving violence in the family context to
receive good quality, professional legal assistance, either free of charge or at
subsidised prices (Petrusic etal. 2012).
Based on the results of the study, recommendations were provided to improve
the Serbian legal framework, as well as the way cases of elder abuse were managed.
Services providing protection and support to older people are not well coordinated
and are fragmented and scattered in different public departments (police, judiciary,
health institutions, centers for social welfare) that do not communicate and share
information with each other in ways that would ensure adequate protection.
A recommendation on how to improve the legal framework suggests that the
Criminal Law of the Republic of Serbia explicitly recognises violence against an
older person in family context as a distinct act and aggravating factor. Such a change
would ensure a deterrent to abuse perpetration and provide adequate punishment of
violent acts targeting older family members who represent a distinct and vulnerable
group in the society.
The second research study by the Red Cross of Serbia on violence targeting older
people was published in November 2015, entitled ‘Introduction to Ageing and
Human Rights of Older People: Pilot Research Study on Financial Abuse of Older
People’ This is the rst study in Serbia looking into the concept of human rights of
older people which included a focus on nancial abuse.
The rst part of this study explores the concept of human rights. The second part
is an overview of international, regional (EU) and national legislative frameworks
related to the protection of human rights of older people and anti-discrimination
regulations. Special attention was given to national legislation related to livelihood
and inheritance. The third part of this report presents the results of an exploratory
study of nancial abuse of older people and case studies related to deprivation of the
legal capacity of older people and the issues arising around life care contracts.
Designed as pilot study, the eld research involved interviews with 140 ran-
domly chosen persons over 65yearsof age who resided in ten different municipalities
N. Todorovic and M. Vracevic
243
in Serbia. Due to the size and characteristics of the sample, the results of the study
are not to be taken as representative in and of themselves, but serve the purpose of
providing useful ndings to develop hypotheses for future research that will have
broader scope.
In the sample, 69% of the participants were female and 31% were male. Sixty
nine percent of the sample lived in urban areas, 19% lived in rural areas and 12%
lived in peri-urban areas (Petrusic etal. 2015).
To assess the risk of nancial abuse, the researchers asked ‘Is someone autho-
rised to manage your bank account?’ Almost 40% of the participants responded
with “yes”. Eight percent of the older people stated that someone was using their
money without their knowledge (Petrusic etal. 2015).
One hypothesis arising from the results of this study was that there is a marked
presence of strong patriarchy in family relations in Serbia that is characterised by a
model of parental self-sacrice for their children. This characteristic increases the
risk of nancial abuse but at the same time makes it more difcult to identify it, due
to the protective instinct towards the child of the parent(s). To further probe this
concept, a question was asked: ‘If you won a lottery, what would you spend the
money on?’ More than 50% of the participants said they would pass the winnings
on to their children or grandchildren while only 9% would use it to travel and 7.1%
would use it to go to a spa (Petrusic etal. 2015).
Further reinforcing the hypothesis of patriarchal relations and existing character-
istics of self-sacrice are the expectations of the child inheriting property after the
passing of marital partner (Petrusic etal. 2015). Services providing protection and
support to older people are not well coordinated and are fragmented and scattered
in different public departments (police, judiciary, health institutions, centers for
social welfare) that do not communicate and share information with each other in
ways that would ensure adequate protection.
Looking to gain a deeper and more comprehensive insight into the phenomenon,
we used a case study method. We analysed two scenarios: one was where a person
was being declared legally incompetent and deprived of legal capacity, and the other
was where there was of termination of a lifelong care contract that was initiated by
the older person. Life support contracts are regulated by the Law on Inheritance and
they stipulate exchange of property for lifelong service.
The case studies showed that despite the law requiring that the legal petition to
deprive a person of their legal capacity must present the facts on which it is based as
well as evidence that establishes these facts as true or believable, in some of the
cases analysed the reasons quoted in the petition were illogical and have not dem-
onstrated that the person was incapable of taking care of her/himself, indicating
possible ageist prejudice.
A second observation is related to the legal obligation of the court to interview
the person to establish the facts and to identify if legal capacity is diminished or
present. However, this criteria may be sidestepped if it is assumed that the interview
could negatively affect the person’s health or if the mental status of the person does
not support the conduct of an interview. In the ve cases examined in this report, it
was observed that the court had not interviewed the persons undergoing the legal
16 Human Rights andElder Abuse: TheCase Example ofSerbia
244
competency assessment. Having in mind that this is a small number of cases, gener-
alisations should not be made but still this does indicate risks to human rights of
older people in terms of being rendered silent and having their rights deprived in
such procedures in Serbia.
As for the scenarios related to termination of life care contracts, six such cases
were studied. Lifelong support contracts are regulated by the Law on Inheritance
and they stipulate exchange of property for lifelong service. It is legally stipulated
that the contract must be written and signed in front of a judge. The judge is legally
obliged to inform the older person that the property described in the contract will
not upon her or his passing be part of the inheritance. This was a particular point of
interest in the research as it was noticed that despite the law granting the option to
dissolve the contract if unsatised with the services, many older people will not
reconsider the arrangement, even if this is clearly to their benet. What scares older
people off is the potential of high court expenses and the risk of being ordered to
reimburse the services already received up to that point. Older people are therefore
often apprehensive of entering such contracts– even though they could ensure basic
quality of life in their older age– because the prevalence of suspicious contracts
seems to be relatively high.
This report made recommendations which include improving the legal frame-
work through amending the Family Law to address issues such as ensuring the older
person’s continued self determination in nancial matters or where their best inter-
ests are central to nancial decision making if incapacity is present.
As for legal capacity, full deprivation of a person of their legal capacity is unac-
ceptable from the perspective of human rights (Fredvang and Biggs 2012) and the
recommendations include changing the legislation as to reect this concern but also
to work with the courts to minimise prejudices towards older age and dementia in
order to ensure that human rights of older people are fully protected.
This study has given initial insights into human rights and nancial abuse of
older people in Serbia, however, it also demonstrates that broader and more in depth
research is necessary, with a special focus on different fraudulent practices such as
telemarketing frauds. Considering there is not adequate protection for older people
in the context of nancial abuse, it is necessary to use broad, inter-sectorial approach
in addressing such issues, including working with banks.
When such elder nancial abuse takes place, older people usually nd legal rem-
edies costly, time consuming and out of their reach, among other things due to
potential additional costs, but also due to the feeling of shame for raising concerns
about their family. However, it is also imperative to recognise that often older peo-
ple do not fully comprehend or even recognise that they are being abused.
All of the data collected served to create a Serbian based body of knowledge on
the phenomenon that was almost completely overlooked in the past. In addition, the
data collected provided us with basis for our other activities: increasing public
awareness on the phenomenon of elder abuse and its prevalence as well as providing
platforms for public advocacy activities ranging from changing the legislation to
challenging ageist stereotypes that are among major contributors to the different
N. Todorovic and M. Vracevic
245
forms of elder abuse (Krug etal. 2002; Nelson 2005) (See Taylor in this book for
advocacy).
The third study undertaken by the Red Cross of Serbia into elder abuse was
undertaken in 2015in cooperation with the ofce of Commissioner for Protection
of Equality. The results were published in a report entitled ‘Well-kept family secret:
elder abuse’ (Jankovic, Todorovic, Vracevic 2015). The research involved telephone
interviewing with a sample of 800 people over the age of 65years (average age of
the interviewee: 73). Findings demonstrated that 19.8% of the population over the
age of 65years in Serbia have been exposed to some form of abuse in their older
age, with 11% reporting the abuse took place over the last 12months. The highest
risk was of nancial abuse, with 11.5% of the population being exposed to some
form of nancial abuse with theft being the most frequently experienced type. More
than thirteen percent (13.5%) of the interviewees stated that they do not have com-
plete control of how they use their nances, indicating the high risk of nancial
abuse. Fifty four percent of the interviewees have reported using their income to
support other members of the household they live in. However, older people fre-
quently do not perceive this as nancial abuse, including situations where they are
not in full control of their nances. For some older people, they reason that they are
old and do not need the money that younger family members may be in more need
of.
Furthermore, 3.9% of older people reported physical abuse, with 2% experienc-
ing it in the last 12months and 0.7% being targeted three or more times in the last
year. Almost eight percent (7.8%) reported psychological/verbal/emotional abuse;
4.6% in the last 12months, with 2.5% experiencing it three or more times in the last
year. In 1.4% of the reports, the perpetrator of this form of abuse was a family mem-
ber and in 3% of the cases it was reported as other people (Jankovic etal. 2015).
Fifty percent of the interviewed older people declined to answer the questions
related to sexual abuse. This may be due to a reticence to discuss sexual abuse due
to its taboo nature. Only one interviewee reported that they were target of an attempt
of sexual contact by a third party.
Neglect was reported by 3.4% of older people and this percentage was higher
(5.1%) for those who need assistance with daily activities than for those who need
no such assistance (2.2%) (Jankovic etal. 2015). This agrees with other interna-
tional studies on risk factors for elder abuse (Pillemer etal. 2016).
In total, 19.8% of older people experienced some form of abuse or neglect with
5.5% reported experiencing multiple forms of abuse. Eleven percent experienced
some form of abuse over the 12months preceding the interview (Jankovic etal.
2015).
In a separate research study on older people living in rural areas in Serbia under-
taken in 2016 (Jankovic etal. 2016), 9% of the interviewed older people reported
having experienced some form of elder abuse or neglect. Nevertheless, ‘Well-kept
family secret: elder abuse’ is the largest research study on elder abuse done in
Serbia. The data on elder abuse in Serbia is quite similar to the data from global and
16 Human Rights andElder Abuse: TheCase Example ofSerbia
246
regional sources in terms of overall prevalence and prevalence of different forms of
abuse (Yon etal. 2017). However, the need for new and additional research into this
phenomenon and its different aspects is still very important especially considering
some slight variation from data presented by studies from European countries
(Pillemer etal. 2016).
The two most recent research studies undertaken by the Red Cross of Serbia,
‘Older People in Rural Areas’ (2016) and “Ageing in Cities” (2018) have not dealt
with elder abuse directly, but have looked into how older people perceive and expe-
rience age-based discrimination. Both studies provided insight into obstacles older
Serbian people have in exercising some of their guaranteed rights (health, social
protection). Such insights are important as age-based discrimination can be treated
as a society-level risk factor for elder abuse (see Chap. 2 by Phelan and Ayalon).
In rural areas in Serbia, 27% of the participants reported having personally expe-
rienced age-based discrimination (Jankovic etal. 2016). The urban areas of Serbia
had a higher gure, with 33% of participants reported age discrimination (Jankovic
etal. 2018). This contrasts with other age groups as it is a signicantly higher than
among than in the general population where 13% report having been discriminated
against on any basis (Poverenik za zastitu ravnopravnosti 2017). These ndings
point to the fact that older people appear to be at a higher risk of discrimination than
general population.
16.3 Awareness Raising
Through our awareness raising activities, the Red Cross try to raise public and polit-
ical understandings and recognition of elder abuse, its scope, complexity and con-
sequences, particularly from a rights based perspective. The Red Cross of Serbia
has marked World Elder Abuse Awareness Day (WEAAD)– 15 June– every year
since 2007, starting 1year after the date was established. In the early years, WEAAD
was the main vehicle for awareness raising, ensuring good media coverage that was
initially peaking around June but in later years spread to the rest of the year. Elder
abuse was practically completely absent from the media and overlooked in the pub-
lic sphere in Serbia in the past. The Red Cross have also organised awareness rais-
ing through advertising campaigns in public transportation vehicles in several cities
in Serbia and a targeted billboard campaign.
Other initiatives to mark WEAAD include the organisation of panel discussions
between professionals working in the elds of health, social work, public service
etc., which focused on the common topics of ageing and elder abuse. In addition to
the media, these meetings also featured practitioners from public institutions and
representatives of organisations not working directly with ageing but interested in
human rights from different aspects (e.g. women’s organisations, organisations of
persons with disabilities) which created a ripple effect of many different stakeholders
starting to independently address the problem of elder abuse. Furthermore, this con-
tributed to the public institutions taking an interest in the topic and engaging with the
N. Todorovic and M. Vracevic
247
issue in a more comprehensive fashion. Additional activity to mark the 15 June
includes regular visits to policy makers by delegations of older people as part of the
global Age Demands Action campaign coordinated by HelpAge International. These
activities have also resulted in the Red Cross establishing partnerships with human
rights institutions such as the national Ombudsman and Commissioner for Protection
of Equality and this had increased the focus on elder abuse in these institutions.
16.4 Advocacy
All the evidence and data collection as well as awareness raising activities cited
above are intertwined with advocacy aiming to improve protection of older people
and prevention of elder abuse. In advocacy, the Red Cross generally works on three
levels: local, national and international.
At a local level, there are networks of Red Cross branches and partnerships with
local grassroots civil society organisations and initiatives. The Red Cross have devel-
oped a one-day workshop curriculum for older people on their human rights with a
large portion of it devoted to abuse and protection from abuse, so through the network
of organisations and initiatives, older people are informed about their human rights
and the ways to access and protect them. This curriculum was shared with partners in
the region: Albania, Bosnia and Herzegovina, Macedonia and Montenegro. In 2016,
the Red Cross supported the development of civil society advocacy networks in
Macedonia and Montenegro. At the same time, the authors have worked with the Red
Cross of Serbia branches to ensure that they are equipped to provide older people who
are suspected of being abused with support ranging from psychosocial support to
assistance with accessing local public institutions and exercising their rights.
At national level, the Red Cross of Serbia is a founding member and coordinator
of a civil society organisations advocacy network HumanaS.The network advocates
for improved protection of human rights of older people and one of its main focuses
is the issue of elder abuse. In 2018, the network had 17 member organisations.
Initiatives of the network are aimed at policy makers to inuence changes in legisla-
tion so that elder abuse is dened as a distinct act of violence by law. Additionally,
the Red Cross works with policy makers at national level to try to contribute to
improving coordination between local level public institutions and services in cases
of elder abuse, including the way the records on these cases are maintained and data
shared between institutions and services. This should lead to making it easier for
older people experiencing elder abuse to report the abuse, going through a well-
designed procedure that minimises additional stress and secondary victimisation.
When it comes to elder abuse as a violation of human rights, at international level
the Red Cross of Serbia works in partnership with different organisations. The Red
Cross are afliate members of HelpAge International network, represent
International Network for Prevention of Elder Abuse (INPEA), are members of
Global Alliance for the Rights of Older People (GAROP) and are participating in
the process of creating the New United Nations (UN) Convention on the Rights of
16 Human Rights andElder Abuse: TheCase Example ofSerbia
248
Older People. The Red Cross also participated in the work of United Nations
Department of Economic and Social Affairs (UN DESA) Expert Group Meeting on
the Violence Against and Abuse of Older Women (2013) as well as participating in
the fth session of the Open-Ended Working Group on Ageing in the UN at a panel,
talking about nancial abuse of older women (2014).
In the process of advocating for the New UN Convention, the Red Cross have
had several meetings with the Ministry of Foreign Affairs of the republic of Serbia,
to discuss the participation of Serbian representatives in the work of the Open-
Ended Working group on Ageing. An older female volunteer of the Red Cross of
Serbia has, with support by HelpAge International, participated in the eighth ses-
sion of the Open-Ended Working Group on Ageing that focused on discrimination
and abuse. The Red Cross is also a regular participant in the meetings of the Working
Group on Ageing organised in the Geneva UN headquarters every year.
All these international advocacy activities are important not only in and of them-
selves, but also in the national context where experiences from the global level are
adapted for use in advocacy at national level.
Another part of the work of the Serbian Red Cross is with the International Red
Cross Red Crescent movement, where our organisation is spearheading the idea that
the movement should be more focused on protecting the human rights of older peo-
ple and more active in nding the ways to support older people affected by or at risk
of elder abuse.
16.5 Way Forward
The Serbian Red Cross plans for the future include work on several different levels.
One focus includes a plan to undertake a larger scale study, using a representative
sample, on the prevalence of elder abuse in Serbia. A second objective is to under-
take a prevalence study of elder abuse in residential care of older people in Serbia.
The only related research study, to date, has been undertaken by a partner civil
society organisation, Amity (Sataric etal. 2018). This study had a very small sample
(75 older women in residential care) and focused on the access to human rights in
residential care institutions in Serbia. Findings demonstrated that 52% of the par-
ticipants did not make autonomous decision to move into residential care– they
were either pressured into accepting the decision or they were not even consulted
about it. The data related to abuse within the institution is very inconclusive though,
with none of the participants reporting experiencing abuse since moving into the
institution (Sataric etal. 2018).
Reported cases of violence against older people in institutions collected by the
Institute for Social Protection from both private and public residential care institu-
tions in 2016 show that the overwhelming majority of cases– 72 out of 74– report
abuse perpetrated by another resident and only two report the abuse was perpetrated
by a staff member. The majority of victims were female and the most prevalent form
of abuse reported was physical abuse (Republicki zavod za socijalnu zastitu 2017a).
N. Todorovic and M. Vracevic
249
Out of all recorded cases, private institutions account for 14 cases and none of these
cases involve a staff member (Republicki zavod za socijalnu zastitu 2017b). This
suggests that additional studies on this topic are needed to shed light on the issue of
elder abuse in residential care institutions as well as increasing such care environ-
ments’ sensitivity to the phenomenon. Despite the fact that the number of studies
across the globe related to abuse in residential care is not high (Yon et al. 2018),
prevalence data from those studies still suggests that the numbers for Serbia seem to
be disproportionally low, especially in relation to abuse perpetrated by staff of resi-
dential care institutions (Yon et al. 2018; World Health Organization 2018). This
last issue is particularly important considering that residential care institutions –
especially private ones– have been mushrooming all over the country in the past
several years.
Other plans include the Red Cross, establishing cooperation with organisations
focusing on other societal groups at risk of abuse, such as women, people with dis-
abilities, ethnic and sexual orientation minorities. This will assist a general aware-
ness of abuse and neglect of all individuals and the duty to ensure equal enjoyment
of human rights.
As a dominant service provider to care of older people, the Red Cross also plans
to focus on deeper cooperation with the health sector, so that more attention is paid
to elder abuse among health professionals. Here, focus will rst be on general prac-
titioners because they are the rst line of professionals encountering potential vic-
tims of abuse and need to provide medical evidence of abuse occurring should the
court case be established.
Finally, the Red Cross recognised that more work should be done on prevention
of abuse through providing support to both formal and informal carers and estab-
lishing support services for older people who are either survivors of elder abuse or
are identied to be at a high risk.
16.6 Conclusion
The Red Cross has undertaken a number of activities in Serbia to address elder
abuse. This includes the generation of local data on elder abuse, awareness raising,
advocacy and national and international activities. For the future, the Red Cross will
also continue engaging in regular advocacy activities related to elder abuse, focus-
ing on improving legal frameworks, better implementation of existing legislation,
using the rights-based approach and promoting the concept of human rights of older
people.
Reecting on the work completed in relation to elder abuse, the are three impor-
tant synergies to be nurtured: by being engaged in research as well as advocacy at
the same time, the Red Cross gained an edge in advocacy activities with good, veri-
ed evidence and knowledge obtained from direct insight into the problem; collab-
orative spirit means being well connected with people and organisations dealing in
this topic not just in Serbia but also globally and this provides essential insights and
16 Human Rights andElder Abuse: TheCase Example ofSerbia
250
experiences of other countries addressing the issue of elder abuse through public
policy. However, this should include working with stakeholders in the eld of elder
abuse, but also with human rights advocates in general and more specically, those
working on protection of rights of specic population groups (women, persons with
disabilities etc.). Our advantage working through the Red Cross is being able to
amplify the message both to local communities, using the network of the Red Cross
of Serbia, as well as at global level through the International Red Cross Red Crescent
Movement.
References
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sion of Older Persons (65+) in Serbia. Belgrade: Red Cross of Serbia.
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109). Belgrade: Red Cross of Serbia.
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za%C5%A1titu-ravnopravnosti-za-2016-godinu.pdf. Accessed 21 Aug 2018.
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16 Human Rights andElder Abuse: TheCase Example ofSerbia
253© Springer Nature Switzerland AG 2020
A. Phelan (ed.), Advances in Elder Abuse Research, International Perspectives
on Aging 24, https://doi.org/10.1007/978-3-030-25093-5_17
Chapter 17
The Emerging Role ofIndependent
Advocacy inResponding toIssues
Affecting Older People inIreland
MervynTaylor
A son can bear with equanimity the loss of his father, but the loss of his inheritance may
drive him to despair (Machiavelli)
17.1 Introduction
While the term ‘independent advocacy’ is relatively new in an Irish context and
advocacy as a practice is still contested territory and a source of some suspicion
among professionals and service providers it does, nevertheless, have deep histori-
cal roots. The act of individuals or groups speaking up for others in order to ensure
that their interests are represented is, of itself, timeless. During the twentieth cen-
tury, out of a diverse range of movements concerned with human, civil, social and
political rights for the individual citizen, there emerged concepts, practices and ser-
vices which can be broadly described as advocacy.
The right to have your voice heard and to participate in making decisions which
affect you is a fundamental principle in a democratic society. It is a principle simply
stated as: ‘Nothing about you/without you.’ Many people face challenges to their
independence due to physical, intellectual, physical or sensory disability, mental
health difculties, lack of family and community supports or an inability to access
public services that meet their needs. Some people communicate differently and
with difculty and some people slowly lose their ability to make and communicate
decisions when a condition, such as dementia, develops over time. Some are abused
and exploited because of their vulnerability. Others feel disregarded or let down by
healthcare services while some are harmed through adverse events or medical
negligence.
M. Taylor (*)
Sage Advocacy, Dublin, Ireland
e-mail: Mervyn.Taylor@sageadvocacy.ie
254
In circumstances where people may be vulnerable, or have to depend on others,
there is a need to ensure that their rights, freedoms and dignity are promoted and
protected. Through support and advocacy the will and preference of a person can be
heard and acted on independently of family, service provider or systems interests.
17.2 The Development oftheConcept ofAdvocacy
inIreland
In 1996, the report of the Commission on the Status of People with Disabilities
(Flood 1996) recommended that advocacy should be provided for residents in insti-
tutional settings and that a legislative framework should be developed to underpin
this in order to ensure access to essential social services and vindicate the rights of
people with disabilities. Other forms of advocacy, such as self-advocacy and citizen
advocacy were also suggested in what was the rst reference to the need to develop
advocacy in a modern Irish context. While mental health legislation (Mental Health
Act 2001) made provision for legal advocacy in reviews of involuntary detention, it
is possible to speculate that no broader understanding of advocacy was even consid-
ered in the context of people with mental health difculties. Further legislative devel-
opments with regard to people with disabilities (Disability Act 2005) led through a
series of independent advocacy initiatives to the eventual development in 2014 of a
National Advocacy Service for People with Disabilities (NAS) funded through the
Citizens Information Board under the aegis of the Department of Employment
Affairs and Social Protection. With the establishment of the Health Information and
Quality Authority in 2009 and the regulation of nursing homes for older people,
references were made to the need to make provision for people to have access to
independent advocates (Health Information and Quality Authority (HIQA) 2016).
As there was no legislative underpinning of independent advocacy, many nursing
homes simply ignored the issue; some genuinely sought to provide access and found
problems with availability and some few denied access to such advocates.
The Assisted Decision Making (Capacity) Act 2015 and the related establishment
of a Decision Support Service in Ireland provides the context for the Irish govern-
ment to comply in full with the United Nations Convention on the Rights of Persons
with Disabilities (UNCRPD) (in particular with the provisions of Article 12 of the
Convention and with the interpretation of Article 12 by the UN Committee on
UNCRPD. This is being progressed further at present through the processing of
Safeguarding Adults legislation which is linked to the work of Safeguarding Ireland.
The Law Reform Commission is now engaged in work to inform the development of
Adult Safeguarding Legislation and it is understood that this will include provision
for a formal role for independent advocates. Codes of Practice being developed by
the Decision Support Service include one for the guidance of persons acting as advo-
cates which could provide statutory recognition for the term independent advocacy.
M. Tay lo r
255
While progress in recognizing the role of independent advocacy and providing a
legislative and regulatory framework in which it can operate continues at a slow
pace, the direction of the journey, if not the exact point of arrival, is becoming clearer.
The Disability (Miscellaneous Provisions) Bill (Houses of the Oireachtas
2016) and a proposed Deprivation of Liberty Bill will address outstanding issues
related to the UNCRPD including the protection of liberties of people in places of
care where issues of custody are involved and independent advocacy may be
required (Browne 2018).
17.2.1 What Is Independent Advocacy?
Independent advocacy can be viewed at two levels – the individual and the
systemic.
At individual level, the focus is on the ‘voice’ of the person, of understanding
their wishes, gathering information to enable them make informed choice regarding
such options as may exist or be created and supporting them to determine their own
best interests and exercise their will and preference. It is about enabling a person to
engage in autonomous decision-making and self-determination, protecting people’s
human and legal rights, safeguarding and protecting vulnerable adults from abuse in
all its forms. All of this can be summed up in the motto chosen by Sage Advocacy
‘Nothing About You/Without You’. In the case of an individual who has signi-
cantly reduced decision-making capacity or who has lost all decision-making capac-
ity, the challenge of ensuring that decisions are made on that person’s behalf, which
are in keeping with their will and preference, is potentially more challenging. For
example, faced with a vocal group of adult children, determined to ensure what they
believe to be in the best interests of their parent is carried out, it can be extremely
difcult for any independent advocate to ask hard questions regarding whose best
interests are being addressed.
At systemic level, the issues of concern to a range of individuals which are simi-
lar in nature, or which share the same root cause, can be addressed by independent
advocacy. This can involve a range of approaches including: lobbying for legislative
and policy change to address gaps in provision where these have been identied;
building collaborative platforms for identifying and managing change; identifying
advocacy champions at various levels. Independent advocacy can therefore be
described as advocacy which is independent of family, (service) provider or systems
interests. Having developed sufcient knowledge of the issues of concern to indi-
viduals, the challenge for providers of independent advocacy is to ensure an effec-
tive balance between addressing the needs of individuals, as they express them, and
addressing the underlying issues which consistently give rise to those needs (see
also Chap. 16 by Todorovic and Vracevic).
17 The Emerging Role ofIndependent Advocacy inResponding toIssues Affecting…
256
17.3 Some Issues Affecting Older People inIreland
The range of issues/challenges facing older people in Ireland are well docu-
mented through many years of policy development. Initiatives ranging from The
Irish Longitudinal Study on Ageing (TILDA)1 to the Forum on Long Term
Support and Care of Older People (Sage Advocacy 2016) have added rich data,
insights and assessments of public opinion. Societal preparation for ageing has
been greatly assisted by programs such as Age Friendly program,2 the Dementia
Strategy (Department of Health 2014) and the National Positive Ageing Strategy
(Department of Health 2013). A noticeable feature of all discourse on ageing in
Ireland is the extent of unanimity on policy and concern with implementation.
This is well expressed in a key question posed in the Report of the Forum on
Long Term Support and Care for Older People; “Why, despite decades of policy
reports and recommendations to government, is there still a systemic bias towards
care in congregated settings and no formal legislative basis for support and care
in the community?” (Sage Advocacy 2016: 6). This bias is reected in the fact
that a Nursing Home Support Scheme (Department of Health 2017) was estab-
lished in 2009 and is heavily regulated whereas a statutory home care scheme is
still some years away as is regulation of home care service provision. The fact
that policy statements emphasize a ‘continuum of care’ and actual implementa-
tion focuses on two separate statutory schemes amply illustrates the gap between
rhetoric and reality.
Income supports for older people are, from the perspective of outside observers,
adequate and the system of ‘Free Travel’ for older people is still regarded as an
important achievement. The role played by social transfers (such as the state pen-
sion for older people) in mitigating some of the harsher effects of public spending
austerity following the economic crash in 2008 has been highlighted even if has not
always been appreciated (McGill 2014).
While the emphasis on nursing home care as the primary response to long term
support and care is widely criticized and support for better provision of support and
care in the home is growing, there has been little public discussion about the denial
of the basic legal and human rights of older people which can arise when care and
custody become blurred and a placement of an older person in a congregated care
setting against their will and without protections for their rights becomes, in effect,
deprivation of liberty. The Citizens Assembly in 2017 held two sessions on the
Opportunities and Challenges of an Ageing Society (Citizens Assembly 2017). It
heard powerful testimony from a woman who had ‘escaped’ from a nursing home
and returned to live at home despite the efforts of her family and the nursing home
(which included threats to call An Garda Síochána (Irish Police)) to convince her
to stay. The long delay in the implementation of the Assisted Decision Making
1 See https://tilda.tcd.ie/publications/
2 The Age Friendly Cities and Counties Program is run by city- and county-based Alliances, involv-
ing senior decision-makers from public, commercial and not-for-prot organizations.
M. Tay lo r
257
(Capacity) Act of 2015 has meant that the Lunacy Regulations (Ireland) Act of
1871, and the system of wards of court which formed the backdrop to Charles
Dickens great novel ‘Bleak House’, has meant that there are now at least 2600
people3 subject to care and custody without adequate checks and balances to pro-
tect their rights.
A related issue where care and custody become blurred can be noted with regard
to delayed discharges from acute hospitals or, as they are more appropriately termed
within the NHS, ‘delayed transfers of care’. Gaining access to necessary healthcare
in an acute hospital can be difcult with signicant waiting times and sometimes
degrading treatment involved in emergency departments through which an enor-
mous level of hospital admissions are made. Despite these pressures on hospital
beds, the process of discharge from hospital, in the absence of appropriate homecare
or because of a risk-averse approach by hospital staff, can lead to older people being
effectively detained against their will. In extreme circumstances, periods of many
months can be involved. A further issue relates to older people at end of life whose
expressed wish to die in their own home remain unconsidered as the institutional
pull of acute hospitals wins out over the policy priority of home care. The domi-
nance of hospitals and nursing homes in the landscape of Irish health and social care
provision both reects and reinforces the medical model of care and marginalizes
opportunities for innovation with regard to new models of support and care focused
around housing with supports.
If the instincts of too many in the healthcare system reect a ‘best interests’
approach and a willingness to ignore the possibility that some care provision has
aspects of custody, it is only fair to point to the lack of systems of review that
might address the lack of understanding and skills regarding issues of consent and
the authoritarian instincts of some of the medical and nursing professions. Even in
the area of safeguarding of vulnerable adults, the Irish Health Service Executive
(HSE) states that its Safeguarding and Protection Teams cannot intervene on a
matter of concern regarding an older person in a private nursing home in the same
way that they can intervene in a HSE owned facility.4 It is interesting to note that
the Report of the Commission on Policing (Commission on the Future of Policing
in Ireland 2018), while necessarily addressing issues of state security, is heavily
focused on the protection of vulnerable people and the need to respect human
rights. The nearest equivalent report in a health and social care context is the all-
party Sláintecare Report (Committee on the Future of Healthcare 2017) which
does not consider the issue.
3 https://www.irishtimes.com/news/crime-and-law/more-than-2-600-judged-incapable-protected-
as-wards-of-court-1.3356429
4 This was pointed out in a Letter of 13th August 2018 from the Chair of Safeguarding Ireland
(National Safeguarding Committee) to the Minister for Health which suggested a way out of this.
17 The Emerging Role ofIndependent Advocacy inResponding toIssues Affecting…
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17.4 Developing aResponse
Any strategy which seeks to address the issue of rights within the systems of health
and social care provision must take account of the emerging potential arising from
a diverse range of issues and initiatives and be sufciently innovative and exible to
enable linkages where these may not be immediately obvious. Health, social care
and legal professions are products of and are inuenced by the society and economy
within which they operate. Key to the development of any strategy has to be the
development of professional awareness as part of a wider process of developing
public awareness. An example of this is the belief, widespread among professionals
and the public that people who are ‘next of kin’ have a level of decision-making
authority over a close relative in certain circumstances. Research undertaken for
Sage Advocacy by Red C (2018) found that over half (52%) of those questioned
believed, that anyone named as ‘next of kin’ can make healthcare or other major
decisions on another person’s behalf. In fact, being named as ‘next of kin’ means no
more than that the named person should be contacted in the event of an emergency.
The widespread belief in the powers of ‘next of kin’ has contributed to older people
being placed in nursing homes against their will, contracts being signed on their
behalf without their involvement, control and dispersal of funds and assets, interfer-
ence with healthcare procedures and considerable wastage of valuable time by pro-
fessionals who have to engage with and often mediate between competing factions
of an extended family. An initiative to promote awareness of existing consent poli-
cies in the health and social care services reinforced with a change of wording on all
paper and digital records systems to delete references to ‘next of kin’ and include a
question regarding ‘who you would like information shared with’ would do much to
change popular and professional understanding and reinforce the rights of older
people in a practical way.
At a higher level, the 2018 Hogan judgment5 which clearly pointed to the need
for legislation to address issues of custody in care situations, has implications for
the operation of the system of wards of court which does not provide the same rights
for older people being considered for wardship as a mentally ill person detained
under the Mental Health Act 2001. The passing of legislation to provide rights for
people being considered for placement in care settings and the full implementation
of the Assisted Decision-Making (Capacity) Act 2015 which will lead to the phas-
ing out of the system of wards of court point to the potential for progress. However,
the extent of progress depends on the convergence of a number of developments
with the associated hope that synergy will develop. It also depends on the extent to
which independent advocacy can contribute to the integration of issues and initia-
tives by making plain the extent to which they are all related and by being able to
5 In a Court of Appeal Judgment on whether a hospital had a right to detain a person against their
will, Justice Gerard Hogan stated that the court was not satised that the hospital had the power to
detain the person which he said amounted to paternalistic entitlement to act in the best interests of
the patients whose capacity is impaired and, in effect, to restrain their personal liberty and freedom
of movement.
M. Tay lo r
259
provide practical supports to individuals and groups of people who are especially
vulnerable so as to build awareness of rights and responsibilities.
Recognition of the importance of rights and of the need to reinforce them through
growing awareness needs to be balanced by an understanding that other social and
familial dynamics can have an impact. Popular perceptions of decision-making
rights can be reinforced by beliefs related to inheritance. The well-intentioned
desire of a parent or grandparent to pass on something to children or grandchildren
can create an ill-intentioned belief in the right of the younger to an inheritance from
the older. It can also mean that those older people who have committed their inten-
tions to paper, in the form of a will, can then nd it difcult to change their will if
circumstances change or their understanding of their offspring’s motivations
changes. The desire of many older people to be self-reliant can be self-defeating
when physical health declines, frailty increases and they start to feel that they may
be a burden on their own family. In such circumstances older people can be extremely
vulnerable to abuse as adult children start confusing the best interests of their parent
or grandparent with their own interests. Creating awareness of these issues among
older people may require a judicious mix of counter-intuitive media efforts as well
as changes in inheritance law and taxes. It may also require a system of incentives
to people to plan ahead; in effect to advocate for themselves when they may at some
future stage be unable to by making clear what their wishes are with regard to
healthcare, places of care and decision-making in the event that they lose the capac-
ity for decision making. Such a system of incentives must include not just incentives
to the public to engage with resources such as ‘Think Ahead’ (Irish Hospice
Foundation n.d), Advance Healthcare Directives and Enduring Power of Attorney,
but also incentives to healthcare professionals to promote these measures with
patients at appropriate times. Crucial to the success of such an approach is an incen-
tive to health and social care systems to enable speedy access to information regard-
ing the forward decision-making plans of individuals and thereby minimizing the
extent of time and resources expended in engaging with family members with dif-
fering interpretations of what a person might or might not want. While the evidence
regarding usage and effectiveness of instruments for forward planning such as
Advance Healthcare Directives and Enduring Power of Attorney is still limited, the
desirability of people being provided with a means to have their voice heard when
they no longer have a voice remains morally compelling. Backed by state incentives
and a determination to undertake cost-benet analysis, the overall effect could well
be a reinforcing of the rights of older people.
17.5 The Role ofIndependent Advocacy
The development of responses to these issues, from an advocacy perspective, must
take into consideration the nature of independent advocacy, the context in which it
currently operates and the emerging landscape in which it will have to operate.
Independent advocacy, to borrow a phrase from Victor Hugo, is ‘an idea whose time
17 The Emerging Role ofIndependent Advocacy inResponding toIssues Affecting…
260
has come’. The slowly changing legislative context, which will likely provide legis-
lative recognition for the practice of independent advocacy, reinforces the growing
support for person-centredness (see Chap. 3 by Phelan and Rickard Clarke).
Insisting that a vulnerable person, or group of vulnerable persons, has a right to have
their voice heard and their will and preference (wishes) taken into account chal-
lenges service providers to put meaning into the term person-centredness. But, if in
an ageing society vulnerability remains inextricably linked with frailty and increas-
ing frailty over extended periods is the result of increasing longevity (Kingston etal.
2018), then the inevitable need for increased health and social care provision will
have to be accompanied by greater provision of advocacy services. The difculty
here is that resources will have to be prioritized. Simple choices will have to be
made between, on the one hand, providing additional professionals who can deal
with specic clinical and social issues in the context of constrained resources and,
on the other, providing people to advocate for individuals so that they can access
existing services as well as lobbying for the provision of additional resources. Such
an approach will, undoubtedly, involve ‘speaking truth to power’, but it will also
mean ‘speaking truths to the powerless’; to tell them hard facts about limited and
possibly non-existent options. This poses the question: ‘how can advocacy be more
strategic in its practice and interventions?’
One of the problems associated with the practice of advocacy is that it is often
called for when situations have already become complicated as a result of many
professionals with differing perspectives and limited control over necessary
resources being unable to progress issues. To add to the complications, the families
of the vulnerable person may be unable to act collaboratively; the difculties may
be even further compounded if one or more of the family are exploiting the vulner-
ability of the older person in some way. Viewed from this perspective, if paramedics
are rst responders then advocates are last responders.
Meaningful responses to these challenges will require a greater focus on strategy
and tactics than resources. There is a need to recognize that the principles and pro-
cess of advocacy do not just belong to advocacy services. In practice, as many ser-
vice providers are willing to advocate for vulnerable people as are the number of
those likely to be challenged by and block access to independent advocacy. A lay-
ered advocacy response is required in which the advocacy roles of professionals are
recognized as a resource but its limitations are also recognized and addressed
through judicious use of independent advocacy, i.e., advocacy which is independent
of family, service provider or systems interests. The development of a systems cul-
ture in which the differing advocacy roles of professionals, family members and
independent advocates can operate is of crucial importance. While many advocacy
providers regard self-advocacy as the ‘gold standard’ of advocacy, without any
sense of irony, it is the experience of Sage Advocacy that representative advocacy is
frequently required by vulnerable adults, older people and healthcare patients.
There is, however, an approach which seeks to develop the role of ‘advocacy cham-
pion’ within care providing organizations; a role which acknowledges that service
providers can act within agreed parameters within an organization or service while
M. Tay lo r
261
relying on the support and, where necessary, the intervention of an independent
advocate. Such a role emphasizes the need for the advocate to collaborate, where
possible, as well as to challenge, where necessary. Creating an awareness of an
advocacy spectrum of self-advocacy, advocacy champion and independent advo-
cacy has the potential to give practical expression to the concept of
person-centredness.
The development of advocacy responses to complex issues involving multiple
levels of support and care provision across a range of providers is enormously chal-
lenging, particularly in a context in which vulnerability often tips the scales of judg-
ment towards safeguarding rather than autonomy, is enormously challenging. In
circumstances of multiple morbidities, complex systems of provision and conicts
of interests, advocacy can be most effective if it is combined with the skills of
mediation and systems integration. This suggests that advocacy services might need
to become ‘service brokers’ as part of the process of gathering information, explain-
ing options and supporting people to make decisions.
If advocacy can reinforce person centredness, respect existing professional roles
while gaining respect for its own important contribution, and push its own boundar-
ies to deliver better outcomes for vulnerable people and innovation in service deliv-
ery, it is going to need to develop and progress an agenda which can demonstrate
both its unique contribution and the extent to which it can complement the work of
health, social care, legal and nancial professionals. If the term independent advo-
cate is to be a ‘protected term’ (Quinn 2018) and if legislation to provide a role for
independent advocacy in the context of deprivation of liberty and safeguarding vul-
nerable adults is increasingly seen as more rather than less likely, it is time that
some form of support and oversight structure be put in place to address core issues
such as standards, training, funding, and coordination. The development of a
National Council for Advocacy must now become part of the wider strategy of all
those concerned with safeguarding vulnerable adults and older people.
The collaborative as well as the challenging nature of advocacy and its practical
role in acting as a systems integrator in support of individuals has the potential to
provide momentum to the development of structures and systems for safeguarding
vulnerable adults. Responsibility for dealing with abuse of older people has been
the responsibility of the health and social care services for many years. In particular,
responsibility has been exercised through social workers organized since 2015in
Safeguarding and Protection Teams.6 While there is anecdotal evidence that the
resourcing of such teams is only about one third of what it should be, it is clear that
the provision of resources alone is not sufcient. The report of the Commission on
the Future of Policing in Ireland states that:
Police increasingly nd themselves dealing with the most vulnerable members of society–
those who are unable to protect themselves from coming to harm or suffering exploitation.
(Commission on the Future of Policing in Ireland 2018: 13).
6 These teams were established within the HSE Social Care Division following the publication of
the Safeguarding Vulnerable Persons at Risk of Abuse National Policy and Procedures (2014).
17 The Emerging Role ofIndependent Advocacy inResponding toIssues Affecting…
262
The report also argues that:
…the prevention of harm should be explicitly identied as a core objective of policing…
[and that]…police need to be equipped with the necessary special response techniques
required in incidents involving vulnerable individuals who may not react well to typical
police interventions. (Commission on the Future of Policing in Ireland 2018: 13).
The placing of vulnerable people, including vulnerable older people, at the heart of
policing strategy is a signicant development and the report also refers to the poten-
tial for integrated teams of Gardaí and social services working in shared accommo-
dation, something recommended by the Mental Health Commission some 9years
ago (Mental Health Commission/An Garda Síochána 2009).
The experience of Sage Advocacy on the ground suggests that inter-agency col-
laboration to safeguard vulnerable adults is still, in many respects, a half-conscious
thought. While the difculties of inter-agency working have been highlighted and
the need for processes of collaboration underlined (McKeown 2012),7 it is clear that
a core of agencies, already represented on Safeguarding Ireland (the National
Safeguarding Committee) such as the HSE, HIQA, An Garda Síochána and the
Department of Employment and Social Protection could, by working together and
by being informed by the work of services such as Sage Advocacy, develop useful
guidelines and effective practices which could mean that if, for example, indepen-
dent advocacy were to be afforded legal recognition of its practice but not legally
enforceable powers (such as access to documents and premises), it would have
ready access to all those key players who in differing ways are charged with safe-
guarding and protecting vulnerable people and their interests.
17.6 Conclusion
In her Foreword to the Quality Standards for Support and Advocacy Work with
Older People, the then Justice of the Supreme Court, Mary Laffoy stated:
Too often we see the issues facing older people as related solely to health and social care.
In doing so we can sometimes forget the fundamental importance of values, standards and
the law in determining the wellbeing of citizens. (Sage Advocacy 2015: 3).
The experience of developing support and advocacy services for older people in
Ireland and further developing them to include vulnerable adults and healthcare
patients suggests that the implementation of the laws enacted or emergent will be
accompanied by a long and challenging battle between two opposing values: best
interests and will and preference.
7 McKeown points out that an effective and inclusive inter-agency process is necessary but not
enough for improving child outcomes; the sufcient condition for improved child outcomes is
effective intra-agency processes to deliver high-quality services and a policy environment that sup-
ports and requires it.
M. Tay lo r
263
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A. Phelan (ed.), Advances in Elder Abuse Research, International Perspectives
on Aging 24, https://doi.org/10.1007/978-3-030-25093-5
A
Advocacy, 4, 7, 8, 27, 54, 58, 62, 69, 80, 123,
158, 198, 201, 209, 244, 245, 247–249,
253–262
Ageism, 4, 11–19, 78–80, 173, 230
Assessment, 4, 15, 26, 27, 32–34, 88, 90–93,
105–107, 111, 143, 175, 197, 198, 200,
202, 208, 210, 244, 256
D
Decision-making capacity, 6, 8, 18, 25–28,
31–32, 91, 92, 112, 129, 255
Dementia, 2, 6, 7, 24–27, 39, 46, 57, 61,
76, 77, 89, 129, 137–144, 174, 182,
183, 188, 190, 203, 208, 209, 230,
244, 253, 256
Dependency, 2, 3, 13, 15, 18, 48, 76, 92,
106–108, 110, 169, 174, 183, 185, 194,
214, 240
Domestic violence, 1, 12, 13, 16, 42, 64, 76,
165, 167, 170, 174, 206, 231, 235, 240
E
Ecological model, 1, 195, 230
Elder abuse intervention, 7, 144, 193–214
Elder abuse prevention, 5, 54, 56–60, 62, 143,
209, 223–235
Empowerment, 4–6, 47, 114, 121–126, 128,
130, 132, 133, 176, 198
F
Femicide, 169
Financial abuse (FA), 2, 12, 41, 60, 74, 85,
101, 122, 142, 155, 172, 194, 223, 242
G
Gender, 2, 6, 11–14, 28, 76, 78, 105, 106,
150–152, 154, 158, 160, 162, 165–176,
188, 194, 197, 224, 226, 229, 230, 240
H
Human rights, 1, 3–5, 7, 14, 15, 17, 18, 23,
28–31, 34, 40, 41, 53, 64–70, 110, 151,
165, 168, 194, 224, 239–250, 256, 257
I
Interagency collaboration, 3, 214
Intersectionality, 1, 6, 160, 168
Intimate partner violence (IPV), 1, 16, 17, 53,
169, 170, 183, 229, 234, 240
K
Keep control, 5, 6, 121–133
L
Legislation, 1, 4, 5, 14, 15, 23–34, 40–42, 44,
45, 47–49, 54, 58, 60, 61, 64, 67, 80,
91, 93, 109, 111–114, 149, 184, 195,
210, 212, 234, 242, 244, 247, 249, 254,
258, 261
Lesbian, Gay, Bisexual and Transgender
(LGBT), 6, 149–162
Index
266
M
Making a Will, 5, 128, 129
Money management, 5, 108, 111,
113–114, 198
N
Next of kin, 8, 258
Non-governmental organizations, 3,
66–68, 235
O
Offenders, 64, 77–78, 80, 183
P
Person centred care, 17, 24–26, 93, 143, 144
Policy, 1, 12, 25, 40, 53, 80, 90, 101, 133, 138,
149, 167, 183, 195, 225, 240, 255
Prevalence, 1, 17, 74, 87, 103, 137, 151, 169,
182, 194, 229, 240
Protection, 1, 12, 23, 46, 55, 73, 86, 107, 123,
151, 167, 193, 225, 240, 254
Public health, 1, 7, 40, 56, 61, 85, 88, 91, 93,
101, 114, 168, 197, 201, 223–235, 239
R
Resident to resident aggression (RRA), 6, 7,
181–191
Risk factors, 2, 5–7, 76–77, 87, 89–90, 106,
137, 139–142, 151–152, 170, 172, 184,
194, 223, 224, 228, 230, 233, 245, 246
S
Safeguarding, 1, 4, 5, 7, 8, 23, 80, 86, 88,
91–94, 101, 103, 109, 111, 113, 114,
123–125, 131, 133, 188, 193, 197, 210,
254, 255, 257, 261, 262
Safety, 79, 80, 85, 91, 92, 130, 176,
198, 209, 211
Self-neglect, 5, 12, 56, 85, 137, 194
Sexual abuse, 2, 12, 41, 73, 171, 194, 230,
233, 245
Social justice, 4, 28, 53, 121, 123
T
Theories, 2, 3, 13, 14, 57, 87, 93, 105–108,
125, 133
U
United Nations Convention on the rights of
Persons with disabilities (UNCRPD),
23, 29, 254, 255
W
Warning signs, 76–77, 111, 127, 128, 191
Index
