What are the meanings and types of elder abuse?

What do we mean by elder abuse?

My review of elder abuse research unearthed two significant areas of uncertainty: the definition of elder abuse and its classifications into different types. The idea of a separate phenomenon called elder abuse was first suggested by two British physicians, Baker (1975) and Burston (1977). Since then considerable efforts have been made to establish some common ground for agreeing a shared definition of elder abuse. Such a definition should enable –

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the specification of the meaning of an expression relative to a language

acceptable to all researchers (Hudson 1991, Johnson 1986, Utech and Garrett

1992).

I would argue that this stance is problematic. For instance, why should the definition be shaped and shared by only researchers or academics? Would it not be more important, more meaningful and practical to have a definition that is shared also by practitioners, policy makers, older people, and caregivers as well as researchers? As Penhale (2010) has pointed out, the lack of a shared definition of abuse has implications for practice, especially as regards criteria for the identification of abuse and determining when intervention is necessary. Consequently, how elder abuse is defined is important because it provides the foundation for prevention, recognition, reporting, and intervention efforts; with the lack of a consensus on what constitutes elder abuse potentially leading to the mislabeling of cases, inappropriate interventions and outcomes that are unresponsive to older clients’ needs (Moon and Williams 1993).

To date, there remains no single globally agreed definition of elder abuse (Penhale 1999); although it is noted that the World Health Organisation (WHO 2002) adopted the UK version (developed by Action on Elder Abuse 1995), which defines elder abuse as being “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”. Globally, there remains considerable debate over the definition of elder abuse, with one of the main reasons being that people’s perceptions are influenced by their cultural context. Such cultural differences are apparent even within the same country.

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For example, Brown (1989) reported that among the Navajo people in the United States, what would appear to an outsider (such as a researcher) to be financial exploitation by family members, was regarded by the tribal older people as their cultural duty and even privilege, to share material belongings with their families. Other Native Indian tribes in the United States viewed elder abuse as a community problem rather than an individual one (Maxwell and Maxwell 1992).

In other studies, Korean older people were observed to be less sensitive to potentially abusive situations than their Caucasian and African counterparts (Moon 2000). The same study also revealed that older Japanese people appeared to tolerate verbal abuse more, compared with other cultural groups. While ‘disrespect’ was identified as a culturally specific form of elder abuse in the Chinese community (Tam and Neysmith 2006); disrespect and ageist attitudes toward older people were also perceived as one of the major forms of elder abuse by older participants living in some Western countries, such as Canada, Austria, Brazil and Argentina (WHO/INPEA 2002).

In Hong Kong, elder abuse was defined by the Social Welfare Department in 2003 as ‘the commission or omission of any act that endangers the welfare or safety of an elder’. One can argue that the current definition used in Hong Kong

is rather vague and despite the vast majority of Hong Kong’s population being Chinese, the official definition of elder abuse is heavily influenced by Western culture / values.

In addition to the overall definition of elder abuse, its classification is also diverse with various taxonomies existing.

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Taxonomies of elder abuse and how older people and professionals perceive them

Another major theme that emerged from a consideration of the elder abuse literature is the proliferation of classification systems intended to capture the varying dimensions of elder abuse. However, the literature reveals that these taxonomies differ. For example, the National Elder Abuse Incidence Study (1998) in the USA categorised elder abuse as including the following seven aspects: physical abuse, sexual abuse, emotional or psychological abuse, neglect, abandonment, financial or material exploitation, and self-neglect. However, in the United Kingdom, the typology of elder abuse adopted by Action on Elder Abuse (1991) includes five elements: physical abuse, psychological abuse, financial abuse, sexual abuse and neglect. In Australia, elder abuse as defined by the Australian Network for the Prevention of Elder Abuse in 1999 included physical, sexual, financial, psychological, social abuse and/or neglect. While in Japan, researchers have categorized elder abuse into five major types: psychological abuse, neglect, financial abuse, physical abuse and sexual abuse (Tsukada et al. 2001). In addition to the five major types of elder abuse listed by Japan, Hong Kong adds ‘abandonment’ to the list. Table 3.1 highlights the similarities and differences amongst different countries in the prevalence and dynamics of elder abuse.

(1) Physical abuse:

This category seems to receive most of the attention in the literature, probably because it leaves recognizable marks on victims. Physical abuse includes behaviours ranging from inflicting pain or injury to murder (Wolf 1986). The US National Centre on Elder Abuse (NCEA 1998) specified examples of elder

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abuse as acts of violence including striking (with or without an object), hitting, beating, pushing, shoving, shaking, slapping, kicking, pinching, and burning. The inappropriate use of medications and/or physical restraints, force-feeding, and physical punishment of any kind are also examples of physical abuse. Table 3.1 Prevalence and dynamics of elder abuse in a selection of countries

Country Types

Australia Canada Hong Kong Japan United Kingdom Unite d States Prevalence 2-10% [Bagshaw et al. 2009] 7.5% [National survey on the mistreatment of older Canadians 2015] 27.5% [Yan and Tang 2004] 17.9% [Anme et al. 2005] 4% [O’Keeffe et al. 2007] 11.4% [Acierno et al. 2010] Physical abuse √ √ √ √ √ √ Psychological / emotional abuse √ √ √ √ √ √ Financial abuse √ √ √ √ √ √ Neglect √ √ √ √ √ √ Sexual abuse √ √ √ √ √ √ Self-neglect √ Abandonment √ √ Social abuse √ (2) Psychological abuse

This type of abuse is not easy to define, measure or detect (Daly and Jogerst 2001). Studies have employed a variety of terms, such as emotional and verbal abuse (Dyer et al. 2000) that have been used interchangeably with psychological abuse. This type of abuse includes various forms of behaviours, such as name- calling, humiliation, isolation, and threat of placement in a nursing home (NCEA 1998, Wolf 1986,).

(3) Financial abuse

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funds, property, or assets”. Examples include using an older person’s money

without authorization/permission; forging an older person’s bank signature; stealing an older person’s money, property or possessions; coercing or deceiving an older person into signing a document; and improper use of power of attorney (Kemp and Mosqueda 2005).

(4) Sexual abuse

Elder sexual abuse is defined as “non-consensual sexual contact of any kind with an elderly person” (NCEA 1998). Research investigating elder sexual abuse is scant. Only five previous studies have been located (Burgess et al. 2000, Holt 1993, Ramsey-Klawsnik 2004, and Teaster et al. 2000). The latter concluded that sexual abuse is perhaps the most understudied and least well- understood form of elder abuse. In my earlier study I found that among 180 first year undergraduate nursing students in a Hong Kong University, none of them identified sexual abuse as a type of elder abuse (Lo et al. 2009).

(5) Neglect

Neglect has been defined as the ‘refusal or failure to fulfil any part of a caregiving person’s obligations or duties to an elder’ (Aravanis et al. 1992). It has been estimated that approximately 60-70% of all cases of alleged elder abuse fall into the category of neglect (NCEA 1998). Neglect is also suspected to account for the majority of elder abuse cases not reported (Tatara 1993). Neglectful abuse has been described as either active or passive: intentional or unintentional (Hudson 1991). Fulmer et al. (1999) clarified that neglect is different and should be distinct from self-neglect, in that the former occurs in the context of a caregiving relationship with another responsible person, whilst

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the latter is the deterioration of well-being from a lack of self-care skills and resources.

As there are different types of abuse, it is likely that there are different causal factors and researchers do not necessarily agree on any one particular model. For instance, elder abuse in England is often primarily framed within the context of medicalization and institutionalization, while in the USA, elder abuse is generally conceptualized as a family problem and placed in the family or domestic violence arena (Aitken and Griffin 1996). Most recently, Penhale (2011), (personal correspondence) points out that, arguably, there is far less medicalization of elder abuse in UK nowadays.

This section has considered the definitions and types of elder abuse and the main conclusion is that the definition and scope of elder abuse clearly varies but that the majority of definitions have been framed within a research rather than a practice framework. This ambiguous situation has led to conceptual uncertainty in terms of both clarity and precision regarding what exactly constitutes elder abuse (Meeks-Sjostrom 2004, Penhale et al. 2000). Such definitional differences across nations have severely limited the ability to draw consistent and meaningful conclusions (Hudson 1988 and 1991, Penhale 2008, Podnieks et al. 1990). The issue of definition is particularly relevant to this study, for one of its chief aims is to explore the definition and meaning of elder abuse among community-dwelling older Chinese people and health professionals living/working in Hong Kong. To assist this, it is necessary to consider existing theoretical frameworks that seek to explain why abuse occurs. The attention is now turned to this aspect.

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3.6.2 Existing theoretical models used to explain the occurrence of elder