Historical Development

Early concerns about mistreatment of older people were raised by doctors who detected a parallel with child abuse and placed the issue in the wider context of the care of older people both in their own homes and in long-term care facilities, emphasizing the importance of good geriatric practice.^4,5 However, an evidence base was slow to develop despite notable exceptions.^6,7 In its absence, abuse was linked to concerns about the stress placed on family caregivers supporting older people, particularly those with dementia. Policy in many countries has drawn on developments from the United States, which advocates the creation of local protocols when abuse is suspected or revealed. In the United Kingdom, policy developments have also responded to professional and pressure group concerns that elder abuse has been insufficiently resourced and prioritized.⁸

Definitions

The WHO⁹ defines elder mistreatment 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” (p. 6). The U.S. National Research Council¹⁰ supplies an operational definition that includes “intentional actions that cause harm or create a serious risk of harm (whether or not harm is intended) to a vulnerable elder by a caregiver or other person who stands in a trust relationship to the elder” and “failure by a caregiver to satisfy the elder’s basic needs or to protect the elder from harm” (p. 40).

Box 112-1 provides definitions of types of mistreatment, including both behavior and effect. The terms elder abuse, mistreatment, and neglect refer to the ill-treatment of an older person (usually defined as older than 60 years) by acts of commission or omission. They may occur in domestic settings (the older person’s own home, a relative’s home, or supported housing), in long-term care facilities (assisted living, nursing homes, and hospitals), or in the community. Some kinds of behavior are criminal acts, such as assault and theft; other forms, such as verbal abuse, the restraint of someone who is aggressive, or apparent overmedication, may be more contingent on particular circumstances. Definitions are important, but multiple terms are used and sometimes overlap. For example, abuse and neglect generally refer to behavior within a relationship connoting trust. This distinguishes actions by those closely linked to the older person (such as family members) or others in positions of responsibility for their care (such as nursing staff or family physicians) from actions by strangers. These boundaries are not always clear; for example, electronic fraud is a growing crime that may also fall under the definition of abuse when the older person is vulnerable because he or she has dementia. A recent trend has been to broaden understanding of abuse to include resident-on-resident abuse in long-term care facilities,¹¹ the characteristics of abusive environments,¹² contextual factors permitting abuse,¹³ and the relationship of abuse to caregiver stress or characteristics.¹⁴

Prevalence and Incidence

Table 112-1 shows prevalence (in percentages) of elder mistreatment in North America, Canada,²¹ the United Kingdom, Ireland, Amsterdam (the Netherlands), and Spain.²² Studies have also taken place in Spain, the Czech Republic, Finland, Sweden, and Germany. The Spanish study²² is one of national community prevalence, indicating a figure of 0.8% reported by older people but 4.5% by caregivers. Some studies of community prevalence in North America were based on telephone interviews.⁶ The U.K. survey was based on individual face-to-face interviews with people aged 66 and older.¹⁶ Overall in this survey, 2.6% of people aged 66 and older living in private households reported that they had experienced mistreatment involving a family member, close friend, or care worker (i.e., those in a traditional expectation of trust or trust relationship) during the past year. When this 1-year prevalence of mistreatment was widened to include incidents involving neighbors and acquaintances, the overall prevalence increased to 4.0%. The Irish study²³ found less neglect but more psychological abuse than the U.K. study. Data from Hong Kong²⁴ and mainland China²⁵ are also available, reporting higher instances of mistreatment than other studies. Variation between national studies cannot be taken to indicate ethnic or cultural differences in prevalence because standardized measurements were not used.

One particular difficulty for studies using the general population is that people who are highly reliant on another person for activities of daily living, and particularly people who have severe cognitive impairment, are unable to participate, except by proxy. In the U.K. and Spanish studies, people with severe dementia or otherwise unable to take part were excluded from the research. In the Dutch study, nonresponse was relatively high for those with mental and physical incapacity (although all were living independently).²⁶ Yet it is precisely these people whom practitioners might identify as most vulnerable or at risk.