Elder abuse is a significant concern globally, affecting older individuals across diverse socioeconomic backgrounds. It represents a violation of human rights, challenging the fundamental principles of dignity, autonomy and respect for older adults. The World Health Organization 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’ (Krug et al, 2002; Roberto, 2016; World Health Organisation, 2022a). Elder abuse, sometimes called elder mistreatment or elder maltreatment, can occur in community and institutional settings and includes psychological, physical and sexual abuse; neglect (caregiver neglect, self-neglect); and financial exploitation (Institute of Medicine, 2002; Dong, 2015; Roberto, 2016; World Health Organisation, 2022a; 2022b).
The World Health Organization (2022a; 2022b) and Yon et al (2017) estimate that one in six people aged 60 years and older experiences abuse annually. In institutions like nursing homes, the rates of abuse are higher, with two out of three staff reporting abuse in the past year (Yon et al, 2019; World Health Organization, 2022a; 2022b). The number of older people experiencing abuse is predicted to increase as a result of rapid population ageing, with the global population of people aged 60 years and older expected to double, from 1 billion in 2019 to about 2.1 billion by 2050 (World Health Organization, 2019; 2022a). Abuse can lead to serious consequences, such as premature mortality, physical injuries, depression, cognitive decline, poverty and placement in long-term care institutions. Despite its severity, abuse remains a low global priority (Lachs et al, 1998; Baker, 2007; Dong and Simon, 2013; World Health Organization, 2022a), receiving little attention (World Health Organization, 2012; Dong, 2017; Teaster et al, 2020; Yon et al, 2020) and resources (World Health Organization, 2012; Connolly and Trilling, 2014; Yon et al, 2020).
The United Nations Decade of Healthy Ageing 2021–2030 aims to address the abuse of older people in a co-ordinated, concerted way (World Health Organization, 2022a). This 10-year initiative involves collaborations among governments, civil society, international agencies, professionals, academia, media and the private sector. The Decade focuses on four priority action areas, including the issue of abuse of older people (World Health Organization, 2022a; World Health Organization, 2022c). It also supports the implementation of the Madrid International Plan of Action on Ageing and the United Nations 2030 Agenda for Sustainable Development, which include targets for eliminating or significantly reducing violence against older people (United Nations, 2002; World Health Organization, 2022a).
Prevalence of elder abuse
The prevalence of elder abuse is often underestimated as a result of under-reporting, social stigma and lack of awareness. According to the World Health Organization (2022a; 2022b), approximately 1 in 6 older adults experienced some form of abuse in the past year, with neglect being the most prevalent type. However, because of the sensitive nature of the issue, the actual figures may be considerably higher (Roberto, 2016).
The prevalence of elder abuse from a nursing perspective is a critical facet to consider, as nurses are often at the forefront of detecting and addressing elder abuse cases. Their role in healthcare settings positions them to recognise signs of abuse, provide care and advocate for vulnerable older adults. Understanding the prevalence of elder abuse within nursing is crucial for developing effective interventions and support systems.
Ho et al (2017) developed a meta-analysis that estimated the pooled prevalence of elder abuse in studies conducted across the globe. The pooled prevalence of elder abuse in third party- or caregiver-reported studies (34.3%) was more than three times that reported in population-based studies (10.0%). Factors contributing to these differences included older adults being reluctant to admit to being abused out of fear (US National Research Council, 2003; Ho et al, 2017), recall bias between healthcare workers and older adults, caregivers feeling guilty and more willing to share their difficulties and third parties, such as family doctors or geriatricians, being more likely to identify elder abuse in third party- or caregiver-reported studies (US National Research Council, 2003; Ho et al, 2017).
There was also significant publication bias in population-based studies, but not third party- or caregiver-reported, studies (Homer and Gilleard, 1990; US National Research Council, 2003; Ho et al, 2017). This bias suggests that some population-based studies were excluded, leading to underestimation of the pooled prevalence of elder abuse and contributing to publication bias. Non-western countries revealed a 10.1% higher prevalence of abuse than that reported in western countries (Ho et al, 2017). This could be because of the strong concept of filial piety in East Asian cultures and the social and cultural expectation for adult children to care for respected seniors in their families (Sooryanarayana et al, 2013; Ho et al, 2017).
Meta-regression was performed to identify moderators that could explain significant heterogeneity in the pooled prevalence of elder abuse in population-based and third party- or caregiver-reported studies (Ho et al, 2017). No moderator was significant, except for the proportion of married older adults in the sample, which contributed to heterogeneity in a positive direction (Ho et al, 2017). Johannesen and LoGiudice (2013) reported that prolonged contact with older adults is a risk factor for elder abuse, but married older adults with better social support and caregivers who do not suffer from burnout delay institutionalisation and associated elder abuse by third parties. Thus, the emotional health status of caregivers plays an important role in mediating elder abuse (Johannesen and LoGiudice, 2013; Ho et al, 2017).
Yon et al (2017) reveals considerable regional variations in the prevalence of elder abuse, with Asia at 20.2%, Europe at 15.4% and the Americas at 11.7%. There are few analyses of how studies' characteristics influence abuse prevalence, and none in the area of elder abuse. Meta-analytical research on childhood sexual abuse suggested that studies using random sampling, compared with convenience sampling, and those with larger sample sizes, rather than smaller ones, were more likely to produce lower prevalence estimates (Stoltenborgh et al, 2011; 2013; Yon et al, 2017). The present study's meta-regression found that these two variables and income classification explained 26% of the variance in elder abuse prevalence. Large sample sizes, random sampling and high-income countries were associated with lower prevalence estimates, although only sample size differences were independently statistically significant (Yon et al, 2017).
Despite several additional analyses, the present study found no significant difference in prevalence of elder abuse between older women and older men (Yon et al, 2017). Few studies have examined gender differences in elder abuse; those that did found mixed results, with some identifying disparate rates across genders (Yon et al, 2014; 2017). However, emerging evidence has shown a weak association between gender roles and abuse (Archer, 2000; 2002). However, Sooryanarayana et al (2013) and Ho et al (2017) reviewed that females were 6.1% more likely than males to be abused, possibly because of their longer lifespan and risk factors, such as loss of independence and cognitive impairment in old age. The subgroup analysis of the subtypes of elder abuse in population-based studies showed that emotional abuse was the most common, followed by financial abuse, neglect, physical abuse and sexual abuse. In contrast, third party- or caregiver-reported studies showed slightly different results, with emotional abuse (71.5%) being the most prevalent subtype (Sooryanarayana et al, 2013; Ho et al, 2017). Most of this research was performed in high-income countries; if more studies from low- and middle-income countries were available, the finding of gender symmetry might not hold (Yon et al, 2017).
Yon et al (2019) conducted a systematic review with a synthesis of prevalence estimates for elder abuse in institutional settings. The results show that the prevalence of elder abuse in institutional settings is high, with 64.2% of staff admitting to elder abuse (Yon et al, 2019). However, caution is needed when interpreting these estimates, as they only provide a partial picture on the extent of the problem and do not indicate the overall prevalence of abuse in the institution (Hawes, 2003; European Commission, 2007; Yon et al, 2019). Studies on older adults' abuse prevalence vary widely, with estimates ranging from 31% in Israel (Cohen et al, 2010) to 86.9% in the USA (Griffore et al, 2009), 53.7% in Germany (Goergen, 2004) for psychological abuse and neglect and 78.8% for overall abuse (Goergen, 2001). Based on self-reported studies by the staff, 64.2% of them admitted to abuse (Yon et al, 2019).
The findings suggest similarities in the magnitude of the problem. The prevalence estimates reported by older residents were highest for psychological abuse (33.4%), followed by physical (14.1%), financial (13.8%), neglect (11.6%) and sexual abuse (1.9%) (Yon et al, 2019). These rates were higher compared to the prevalence rates in the community settings as reported by older adults: psychological (11.6%), physical (2.6%), financial (6.8%), neglect (4.2%), and sexual (0.9%) abuse (Yon et al, 2017; 2019).
Risk factors for victims of elder abuse include being female, presence of a cognitive impairment and disability and being older than 74 years old (Juklestad, 2001; Rubio Herrera, 2005; Sethi et al, 2011; Yon et al, 2019). Research on elder abuse occurring in the community found that the majority of the victims were women, and 83% of the sample included in this meta-analysis was women (Habjanič and Lahe, 2012; Yon et al, 2019). The greater share of women in institutional care is consistent with the statistical profile of long-term care facilities in North America, where findings showed that nearly four out of the five residents in care homes are women (Gasior et al, 2012; Yon et al, 2019).
There is a strong association between increasing dependency and elder abuse occurring in both community and institutional settings (Lachs et al, 1994; Rubio, 2005; Yon et al, 2019). The risk of dependency also increases with age, with the majority of the sample included in the meta-analysis being 75 years and older. Additionally, an increased presence of qualified nurses was associated with a reduction in resident abuse risk (Yon et al, 2019).
Growing reliance is closely linked to elder abuse that takes place in community and institutional contexts (Lachs et al, 1994; Rubio, 2005; Yon et al, 2019). As people age, there is an increased danger of reliance. Furthermore, a higher chance of misuse has been linked to deteriorating health in Ireland (Naughton et al, 2010) and individuals requiring assistance with activities of daily living in Germany (Goergen, 2001). These results align with the sample characteristics found in the meta-analysis, which showed that those who were abused in institutional settings had weaker health and relied more on staff for help with Activity Daily Living than those who were not abused (Yon et al, 2019). A tiny sample of the elderly residents in the research based on staff self-reports had dementia diagnoses (Yon et al, 2019). Drennan et al (2012) discovered that between 3.4% and 18.5% of the residents who have been abused by staff had dementia. Older residents in the institutions had many of the risk factors associated with abuse. Many of the risk indicators linked to abuse were present in the older institutionalised individuals. Their living conditions may have contributed to these risk factors (Yon et al, 2019).
Residential institutions for the elderly, such as nursing homes, may be stressful places. When asked what their top stressors were, employees said that time constraints and a lack of staff were to blame (Goergen, 2001; Drennan et al, 2012; Yon et al, 2019). Studies have shown that employees who self-reported abusing others felt emotionally spent (Goergen, 2001; Drennan et al, 2012; Yon et al, 2019). Furthermore, a strong link between abuse and a high resident-to-registered-nurse ratio was discovered (Goergen, 2004; Yon et al, 2019). It was also shown that a lower likelihood of resident abuse was connected with a greater number of certified nurses (Goergen, 2004; Yon et al, 2019). Yon et al (2019) found that there was significant variance in the professional experience and training of the personnel. In one study, only 48% of the staff were qualified nurses in the field of elder care or medical care (Goergen, 2001), and in another study, only 10% of the staff were college graduates (Pillemer and Bachman-Prehn, 1991).
Previous studies have indicated that proxy reports might be more effective at detecting abuse (Pillemer and Finkelhor, 1988). Moreover, while efforts have been made to ensure homogeneity of the study samples and to exclude studies with residents with dementia, a small proportion of the samples included residents with dementia.
Conclusions
Elder abuse is a complex issue that demands attention at various levels, including societal, institutional and individual. Addressing elder abuse requires concerted efforts involving research, policy development, education and community engagement. By understanding its multifaceted nature and implementing comprehensive strategies, nurses can work towards preventing and mitigating the devastating impact of elder abuse on older adults.
Elder abuse has severe health, social, and economic consequences for victims, their families, and society. Prevention is more cost-effective than dealing with the consequences of abuse. The World Health Organization global strategy and action plan on ageing and health (2016–2020) and the World Health Organization strategy and action plan for healthy ageing in Europe (2012–2020) affirm the rights of older persons to live with dignity. Strengthening health and long-term care systems is crucial for quality person-centered care. Building capacity of multidisciplinary professionals through training and exchange of good practices across sectors is crucial for preventing elder abuse.
The quality of services requires improvement, particularly through better adaptation to the special needs of older people with functional limitations. The strategy calls for incorporating the latest evidence of good practice into national policies and programming to prevent elder abuse. The urgency of the demand for better, higher-quality care of older adults is highlighted, particularly in middle- and high-income societies. Despite higher rates of abuse and neglect in institutional settings, elder abuse has not achieved the same public health priority as other forms of abuse. Greater attention and resources are needed to ensure nursing and residential home facilities strike a balance between providing care for older residents and ensuring staff support through training, education, and adequate manpower and wages.
Key points
- After the analysis of systematic reviews, the pooled estimate of elder abuse and neglect that took place in institutional settings during the previous 12 months, 64.2% of staff members acknowledged engaging in abuse.
- According to prevalence estimates for abuse subtypes provided by elderly inhabitants of the facilities, psychological abuse was most common, followed by financial, physical, neglectful and sexual abuse.
- Rigid prevalence research on elder abuse in institutions is lacking, particularly in low- and middle-income nations.
- The need for the health and social sectors to provide better care for senior citizens and improved training for workers in care management is heightened by the high incidence of elder abuse in institutions.
CPD reflective questions
- Consider a case from your practice where you suspected elder abuse. What were the indicators, and how did you approach the situation? How might awareness of prevalence data and risk factors have influenced your assessment?
- Reflect on a scenario where you were unsure whether to report a case of suspected elder abuse. What were the challenges, and how did you resolve them? What steps could you take in the future to overcome similar barriers?
- What are the key risk factors for elder abuse in both community and institutional settings, and how can community nurses effectively identify and screen for these risk factors during routine assessments?
- How does emotional intelligence among nurses impact the prevention of elder abuse, and what strategies can be implemented in community nursing to enhance emotional intelligence and reduce the risk of mistreatment of older adults?