Elder abuse is defined as a violation of a vulnerable older person’s human and civil rights by another person(s).3, 5 This definition specifies that these acts are abuse when they happen to a ‘vulnerable person’. Older people are more likely to be vulnerable due to more physical and cognitive impairments, but there is nothing inherently different about how abuse should be identified and managed in younger and older adults, and they are protected by the same guidelines and legislation.4 Like domestic violence, elder abuse can also occur in an older person who is physically well and has mental capacity.

Different types of abuse are recognized. Verbal or psychological abuse encompasses acts such as screaming and shouting at an older person, calling them names, threatening, humiliating or ‘scapegoating’ them. Physical abuse includes non-accidental use of force against an older person, such as hitting, shoving or handling them roughly in other ways, and also inappropriate use of medication, restraint or confinement. The over-prescription and use of as-required medication has attracted considerable attention of late in the UK. Around 100 000 older people in UK care homes are prescribed antipsychotic drugs, often in the absence of psychotic symptoms.

Neglect is defined as ignoring medical or physical care needs, failure to provide access to appropriate health or social care or withholding of the necessities of life, such as medication, adequate nutrition and heating. Financial and sexual abuse involve persuading someone to enter into a financial or sexual transaction to which he or she has not consented or cannot consent. Finally, discriminatory abuse is defined as harassment, slurs or other abusive behaviour towards an older person because of age, race, gender, disability, sexual preferences or other personal characteristics.

Among people providing care, there is often a lack of consensus about what constitutes abuse. While health professionals, family carers and older people are likely to agree that the most serious types of abuse, such as physical violence, should be defined as such, there is often less agreement about other types of behaviour. For example, while locking a person with dementia in their house all day alone to prevent wandering would constitute abuse according to No Secrets, less than two-thirds of English family carers, medical students and mental healthcare professionals thought that this scenario was abuse when presented with it in a vignette.6, 7

Most people agree that behaviour has to reach a certain threshold of severity or frequency to constitute abuse. Shouting at someone angrily once, for example, may be accepted within all emotional relationships. Although the parameters change when one member is dependent and vulnerable, this does not mean that such actions automatically constitute abuse. Most abuse measures use cut-points for how frequently a behaviour must be reported to be considered abusive. For example, the Pillemer criteria define abuse caseness as verbal or neglectful acts occurring ≥10 times per year and physical or financially abusive acts at least once per year.8 The Modified Conflict Tactics Scale (MCTS) asks whether abusive acts have happened never, almost never, sometimes, quite frequently or almost always, and defines an ‘abuse case’ as an abusive act happening at least sometimes in the last 3 months.9

In clinical practice, standardized measures of abusive behaviour are not generally used and there is variation among clinicians regarding the thresholds for considering behaviour abusive and for acting on these concerns. Thinking about abuse as either happening or not can lead to an ‘all or nothing’ response (social services referral of only most serious cases and ignoring others). Detecting and actively managing behaviour that is less severe in nature and frequency may lead to help being given before the problem becomes more serious.

Elder abuse is inherently difficult to study. It is a hidden offence, often perpetrated against vulnerable people (many with memory impairment), by those on whom they depend. Prevalence estimates are influenced, and possibly underestimated, by the fact that many older people are unable, frightened or embarrassed to report its presence. Prevalence estimates of abuse vary greatly between studies and this is partly explained by the different thresholds used to define significant abuse. In the 2007 CARD (Caring for Relatives with Dementia) study of family carers of people with dementia recruited from English old-age psychiatric services, the 3 month prevalence of significant abuse reported by carers against the person they were caring for, as defined by a screening instrument, was 34%, but when we asked a panel of old-age psychiatrists to review the carers’ responses, they agreed that they would be clinically concerned in 6.8% of cases.10 The act of abuse does not imply intent and in many cases the carers may not have viewed their own actions in this light.

Rates of abuse are particularly high among vulnerable people, including those with dementia. Around one-quarter of vulnerable older people (e.g. those receiving home care services) reported significant levels of psychological abuse. Rates of elder abuse in UK care homes have not been studied, although in other Western countries, one in six care home staff admit psychologically abusing people in their care and four-fifths observing abuse if asked.

When health professionals or researchers look for evidence of abuse as opposed to asking older people about it, they find less, nearer 5% in vulnerable older people, probably because they are only detecting more serious physical abuse or neglect with physical evidence. The number of abuse cases reported to authorities is low. Unlike in the USA, the UK does not have a system of mandatory reporting of all abuse and neglect cases, so data are not widely available from about the prevalence of cases of elder abuse reported to social services.

The prevalence of abuse in the older general population is lower than in vulnerable groups. Around 5% reported significant abuse over a period of 1 month. Most of this is psychological, verbal and/or financial abuse.11 In the largest UK survey of elder abuse to date, 4% of older people living in private homes reported abuse. People with cognitive impairment were excluded from this survey.12

The causes of abuse are complex and varied. Older people who are more dependent because of physical or cognitive impairment are more at risk of abuse. In addition to requiring more care, they are less able to leave or report an abusive situation. Older people with mental health problems, who are more depressed or have suicidal thoughts, also report more abuse.