Abuse of older people

What is ‘elder abuse’?

2.25     The most widely known definition of elder abuse is that provided by the World Health Organization (WHO). It defines 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.^[40]

2.26     This description is used across a range of government and non-government bodies in Australia.^[41] Generally, five forms of elder abuse are distinguished: physical, psychological, financial, sexual abuse, and neglect.^[42]

2.27     The definition of elder abuse does not include all abuse of older persons, but is limited by the relationship between the abuser and the older person—that is, when they are in a relationship where there is an expectation of trust. This will include an expectation of trust as a result of an ‘affective relationship’, such as family members, friends, and informal carers, and those in a ‘functional position of trust’, such as paid carers and some professionals.^[43]

2.28     The Terms of Reference for this Inquiry refer to abuse by ‘formal and informal carers, supporters, representatives and others’. The inclusion of ‘formal’ carers means that abuse by paid carers has been considered in the Inquiry, for example in relation to aged care.

2.29     There is limited evidence available about the extent of elder abuse in Australia. To assist in remedying this, the ALRC recommends in Chapter 3 that there be a national prevalence study of elder abuse.^[44] In an Australian Institute of Family Studies research report into elder abuse (the AIFS Report), Dr Rae Kaspiew, Dr Rachel Carson and Professor Helen Rhoades summarise what can be drawn from the currently available information:

The available evidence suggests that prevalence varies across abuse types, with psychological and financial abuse being the most common types of abuse reported, although one study suggests that neglect could be as high as 20% among women in the older age group. Older women are significantly more likely to be victims than older men, and most abuse is intergenerational (ie, involving abuse of parents by adult children), with sons being perpetrators to a greater extent than daughters. For some women, the experience in older age of family violence, including sexual assault, represents the continuation of a lifelong pattern of spousal abuse. Evidence on elder abuse occurring outside of a familial context (eg, in care settings) is particularly sparse.^[45]

2.30     The WHO has noted that research in other predominantly high-income countries has found ‘wide variation in rates of abuse in the preceding 12 months among adults aged over 60 years, ranging from 0.8% in Spain and 2.6% in the United Kingdom to upwards of 18% in Israel, 23.8% in Austria and 32% in Belgium’.^[46]

2.31     The terminology of ‘elder abuse’ may not be appropriate to some communities. For example, the National Aboriginal and Torres Strait Islander Legal Services said that in the Aboriginal and Torres Strait Islander community, in addition to referring to the age of a person, ‘elder’ is also ‘a title of respect’.^[47] Similarly, in CALD communities there may be difficulties in ‘translating the term “elder abuse” in different cultural contexts and languages’.^[48]

Difficulties of definition

2.32     A number of complexities exist in describing elder abuse, particularly in relation to the concept of ‘age’, and the relationship of elder abuse with other forms of interpersonal violence.^[49] The WHO definition captures a wide range of conduct ranging from intentional to unintentional abuse. As such, it may be said that the term elder abuse ‘does not represent a single problem, but many different problems’.^[50]

Age

2.33     Using chronological age as a marker for a distinct form of abuse carries with it some difficulties. As Professors Thomas Goergen and Marie Beaulieu have noted, ‘it is hard to see how victimization and their consequences should change categorically by reaching a certain minimum age’.^[51] Others have argued that the development of the concept of ‘elder abuse’ should be seen in the context of broader understandings about ageing:

the concept of ‘elder abuse and neglect’ was developed in an era when older people were identified as a homogenous group based on chronological age and were marginalized by an understanding of their declining capacities that was associated with their exclusion from the labor market and with a perception that their roles in society should be increasingly limited.^[52]

2.34     Increasing diversity over the life course, particularly with regard to shifts in expectations about retirement from paid work, has implications for distinguishing ‘elder’ abuse as a specific form of abuse. Moreover, the abuse of older people shares some characteristics with the abuse of other groups of people who may be at heightened risk of abuse, such as people with disability. Such groups are often referred to as ‘vulnerable’, although the Law Commission of England and Wales has expressed a preference for the term ‘adults at risk’, because of

concerns that the term vulnerable adult appears to locate the cause of abuse with the victim, rather than placing responsibility with the actions or omissions of others. It can also suggest that vulnerability is an inherent characteristic of a person and does not recognise that it might be the context, the setting or the place which makes a person vulnerable.^[53]

2.35     However, there may be some factors that are associated with ageing, particularly entering into very old age, which mean that a person is more at risk of a specific kind of abuse. Locating these risks as being intrinsic to ageing, rather than the result of a more complex interplay between ‘personal, interpersonal and systemic factors’, is difficult.^[54] Nonetheless, Goergen and Beaulieu have contended that it is important to maintain a distinction between elder abuse and the abuse of other groups of adults, arguing that

[p]henomena of abuse, quantity and quality of risks, vulnerability indicators, coping resources and approaches to intervention are too distinct to synthesise all these fields under a heading of ‘abuse of (vulnerable) adults’.^[55]

2.36     As Goergen and Beaulieu have noted, the very old ‘generally have a reduced exposure to risks of becoming a victim of violent acts in public spaces and by strangers’, mirroring ‘age-related changes in lifestyle, interpersonal contacts, mobility outside the home, and spatial environments often insufficiently adapted to older persons’ needs’.^[56] While risks of ‘public sphere’ victimisation may reduce, the increased prevalence of functional limitations, and the need for assistance with activities of daily living, may heighten the risk of abuse by those in a relationship of trust with the older person.^[57]

2.37     There are advantages to retaining a focus on elder abuse as a distinctive social problem that requires targeted research, prevention and response strategies. However, in this Inquiry, the ALRC has generally avoided making law reform recommendations that are targeted solely at ‘older’ people. Instead, it has recommended that a National Plan be developed to combat elder abuse, to provide national leadership and coordination of strategies (including legal reforms) to prevent and respond to elder abuse.

Relationship with family violence

2.38     Elder abuse is often committed by a family member of the older person—notably, by adult children, but also the older person’s spouse or partner. The essence of elder abuse in the WHO definition is the harm or distress caused by a person in a position of trust. Family violence exhibits similar dynamics. It is defined in the Family Law Act 1975 (Cth) as meaning ‘violent, threatening or other behaviour by a person that coerces or controls a member of the person’s family or causes the family member to be fearful’.^[58]

2.39     The approach reflected in the WHO definition is wider than the concept of ‘family violence’, in that the relationships of trust extend more widely than ‘family’. However, elder abuse is closely related to family violence and, as Dr John Chesterman observed, ‘elder abuse is often also an instance of family violence’.^[59] The Victorian Royal Commission into Family Violence included specific coverage of violence against older people, noting that elder abuse and family violence are often used interchangeably in policy documents and statistics.^[60]

2.40     Like family violence, elder abuse can be physical, sexual, psychological or financial in nature, and is usually committed by a family member; and available research also suggests that women are more likely to experience elder abuse than men.^[61] Some instances of elder abuse may be a continuation of family violence that began when the perpetrator and victim were not old. In other cases, while the perpetrator may be a family member, and thus the abuse could also be described as ‘family violence’, ageism, cognitive impairment of the victim, social isolation or relationships of dependence as well as gender may be important factors in the abuse.^[62] 

2.41     There may be some differences in the dynamics of family violence and elder abuse.^[63] Family violence is often characterised as a manifestation of power and control.^[64] There is less agreement about the dynamics of elder abuse.^[65] The AIFS Report noted that

[p]rogress towards understanding elder abuse and developing effective response and prevention measures,  are  recognised  to  be  considerably  less  well  developed  than  in  other  areas  of  interpersonal violence, including family violence and child abuse.^[66]

2.42     A particular manifestation of elder abuse is financial abuse, which appears to be one of the most common forms of elder abuse. Changing social attitudes to intergenerational wealth transfer in families are important considerations in developing an understanding of elder financial abuse. As the AIFS Report noted:

generational attitudes and expectations in relation to asset transfers before or after death, and the broader question of attitudes and expectations in relation to mutual or non-mutual intergenerational support in terms of material resources and care, form an important part of the backdrop to the social and economic dynamics that may influence the conditions in which elder abuse occurs.^[67]

2.43     Whether abuse of an older person is described as elder abuse or family violence can have an impact on services available to the older person to respond to the abusive behaviour. For instance, family violence services, such as crisis accommodation, that largely cater for women and children may not be suitable for older victims.^[68]

Definition and measurement

2.44     Consensus on a definition of elder abuse is important for developing an evidence base about it. As the AIFS Report observed, having identified the similarity of elements in a number of definitions, ‘the absence of a precise agreed definition is considered problematic for a range of reasons, not the least of which is the difficulty in measuring elder abuse’.^[69] Commenting on previous international studies that sought to measure the prevalence of elder abuse, the authors of a 2007 report on a study of prevalence of elder abuse in the UK noted that ‘[v]ariation in prevalence estimates is heavily influenced by differences in methodology’, including differences in definition.^[70]

2.45     The A:RC considers that, to obtain a full picture of the abuse of older people, a broad description of elder abuse needs to be used, like the WHO definition. This can serve a range of purposes, including to gain a better understanding of the experiences of older Australians. The information obtained through using a wide definition can inform the development of a wide range of policy responses, form community education to criminal offences.

Categories of elder abuse

2.46     Commonly recognised categories of elder abuse include psychological or emotional abuse, financial abuse, physical abuse, neglect, and sexual abuse. These types of abuse are considered throughout this Report. A short overview is set out below.

Psychological abuse

2.47     Psychological or emotional abuse appears to be one of the most common types of elder abuse,^[71] and includes verbal abuse, name calling, bullying and harassment.

2.48     Over a third of calls that reported abuse to a Victorian elder abuse helpline over two years were related to emotional abuse.^[72] Verbal abuse was the most common complaint,^[73] followed by ‘pressuring, intimidating or bullying/harassment’,^[74] and ‘name calling, degrading, humiliating or treating the person like a child, in private or public’.^[75]

2.49     Other examples of psychological abuse include: repeatedly telling an older person that they have dementia; threatening to withdraw affection; and threatening to put an older person into a nursing home.^[76] Stopping an older person from seeing family and friends may also be psychological abuse or ‘social abuse’.

2.50     A US national study found that being ignored, humiliated or verbally abused were commonly reported types of ‘emotional mistreatment’ of older people living in the community.^[77]

Financial abuse

2.51     Financial abuse appears to be the other most common type of elder abuse, accounting for over a third of the calls that reported abuse to the Victorian helpline.^[78] Common types of financial abuse were: someone incurring bills for which the older person is responsible;^[79] someone living in the older person’s home for reasons other than for the benefit of the older person;^[80] someone stealing the older person’s goods;^[81] ‘threatening, coercing or forcing an older person into handing over an asset’;^[82] and abusing power of attorney arrangements.^[83]

2.52     The US study found that spending money without permission, forging signatures, and forcing someone to sign something, were commonly reported types of financial elder abuse.^[84]

2.53     Other behaviours that may, in some circumstances, be financial abuse include: refusing to repay a loan; living with someone without helping to pay for expenses; failing to care for someone, after agreeing to do so, in exchange for money or property; and forcing someone to sign a will, contract or power of attorney instrument.^[85] Many similar examples were provided by stakeholders, and are discussed throughout this Report.

Physical abuse

2.54     Calls to the Victorian helpline reported a range of physical abuse, including: pushing or shoving;^[86] kicking, punching, slapping, biting or burning;^[87] and rough handling.^[88]

2.55     Australian crime statistics suggest that older people are less likely to be murdered, robbed or physically assaulted than younger people.^[89] But some types of physical abuse of older people may not be caught by these statistics—for example, the improper use of ‘restrictive practices’ in hospitals and residential care facilities. Examples of restrictive practices include restraining a person with ropes or belts, locking someone in a room, or unnecessarily giving someone a sedative.

Neglect

2.56     The WHO definition considers that elder abuse can be the result of intentional or unintentional neglect.^[90] Neglect includes failing to provide an older person with such things as food, shelter or medical care. Family members may be responsible for providing such ‘necessities of life’. Some may receive a social security payment for providing care to an older relative. Staff in residential care facilities and others who provide in-home care may also be responsible for providing such care.

2.57     Neglect was the subject of relatively few calls to the Victorian helpline: only four people complained of others failing to provide an older person with the necessities of life, and one person said that someone received the carer’s allowance but did not provide care.^[91]

2.58     Forms of neglect found by the US study included: failing to clean the house or yard; failing to obtain or cook food; failing to obtain medicine; failing to help the person get out of bed, dressed and showered; failing to make sure the bills are paid.^[92]

Sexual abuse

2.59     Sexual abuse includes rape and other unwanted sexual contact. It may also include inappropriate touching and the use of sexually offensive language.

2.60     Sexual abuse of older people may be uncommon compared to other types of elder abuse.^[93] Australian crime statistics also suggest that older people are significantly less likely to be the victims of sexual assault than younger people, particularly younger females.^[94] Sexual assault was also the smallest category of assault found in the US study. However, a 2014 research study stated that, while the ‘idea of older women as victims of sexual assault is relatively recent and little understood … it is becoming increasingly evident that, despite the silence that surrounds the topic, such assaults occur in many settings and circumstances’.^[95]

Risk factors for abuse

2.61     Risk factors for elder abuse may be said to arise out of the interaction of features relating to individuals, their relationships, and community and society.^[96] As with other evidence about elder abuse, more research is needed on risk factors for abuse. However, the WHO has assessed that there is strong evidence for the following risk factors in elder abuse, in relation to the person experiencing the abuse:

• dependence;
• significant disability;
• poor physical health;
• mental disorders (such as depression);
• low income or socioeconomic status;
• cognitive impairment; and
• social isolation.

2.62     For the perpetrator, there is strong evidence that the following are risk factors:

• depression;
• substance abuse: alcohol and drug misuse; and
• financial, emotional, relational dependence on the abused.^[97]

2.63     There is strong evidence that living alone with the perpetrator is a risk factor for violence. Other risk factors for which there is some evidence are social isolation, and being aged older than 74 years. There is also some evidence that women are more at risk of elder abuse than men.^[98]

Elder abuse in particular communities

2.64     The nature and dynamics of abuse experienced by older people may be influenced by their being part of one or more particular communities. However, limitations in available research about elder abuse also exist for research into the dynamics of abuse in particular communities. The AIFS Report noted:

As the dynamics of elder abuse are context dependent, there remains much to be understood about the extent to which the dynamics of elder abuse are different or similar in varying contexts, and the extent to which different responses may be required.^[99]

2.65     There has been limited research on elder abuse in Aboriginal and Torres Strait Islander communities. The AIFS Report concluded that ‘substantially more work is required to understand and conceptualise elder abuse in the Aboriginal context, especially among different groups in different circumstances, given the diversity among ATSI communities’.^[100]

2.66     A Western Australian study has suggested that most concerns about abuse in Aboriginal communities relate to taking advantage of an older person’s financial resources. However, cultural expectations relating to kinship structures and sharing and reciprocity may complicate the way in which abuse is experienced and understood in those communities.^[101]

2.67     For CALD groups, cultural expectations relating to family responsibilities may inform the way in which abuse is experienced and understood in different communities. For example, it may be that a cultural norm in some communities exists that adult children are responsible for decision making concerning their elderly parents.^[102] Additionally, ‘cultural expectations around family privacy may prevent older people from recognising, disclosing, and/or reporting abuse, particularly when it is perpetrated by family members’.^[103]

2.68     For some older CALD people, limited English skills may contribute to social isolation, increase dependence on family members, and in turn increase vulnerability to exploitation and abuse.^[104]

2.69     For people living in rural areas there may be distinct dynamics at play, particularly in the context of farming families. The AIFS Report noted that there may be ‘complex and potentially conflictual dynamics around farming properties with the multi-generational interests involved where the farm is the family business’:

These included complications about the treatment of farms as inheritance, and the balance between providing for children and maintaining the family business, placing one child in a different position from the others, and the treatment of labour and other contributions to the improvement of the farm in estates.^[105]

2.70     In the context of family violence, it has been suggested that in rural and regional areas, issues such as social and geographic isolation, limited access to support and legal services, as well as complex financial arrangements and pressures, including limited employment opportunities, may heighten vulnerability and shape the experience of violence.^[106]

2.71     Older lesbian, gay, bisexual, transgender and intersex (LGBTI) people may experience abuse related to their sexual orientation or gender identity. For example, an LGBTI older person may be abused or exploited by use of threats to ‘out’ a person. Abuse may be motivated by hostility towards a person’s sexual orientation or gender identity. Additionally, LGBTI people may rely on ‘families of choice’ rather than biological family members—and may face either abuse by these people, or a failure by services to recognise and include these people as family members.^[107] Older LGBTI people may also be reluctant to disclose their sexual orientation or gender identity to services for fear of discrimination.

2.72     Additionally, older LGBTI people have a higher exposure to other risk factors for abuse: for example they have a higher likelihood of diagnosis of treatment for a ‘mental disorder’ or major depression than the general population of older people.^[108] They may also be at increased risk of social isolation, which may increase their vulnerability to abuse.

2.73     People with cognitive impairment or other forms of disability have been identified as being more vulnerable to experiencing elder abuse. Where a person has a disability, this will often be correlated with other risk factors: the need for support and assistance, as well as an increased likelihood of social isolation and lower socioeconomic resources.^[109]