![]()
1Elder abuse: an introduction
Amanda Phelan
Introduction
Abuse of older people is a growing challenge in all societies. This is particularly pertinent as demographics demonstrate a global ageing population. For example, Leeson and Harper (2008) indicate that approximately 8 per cent of the world's population was aged 60 years and over in 1950, but by 2006 this figure had increased to 11 per cent, with projections of a rise to 22 per cent by 2050. Elder abuse can occur in any setting that includes older people and in any socio-economic group. The topic of elder abuse has a relatively recent history in public discourse, but there are challenges in definition, understandings and constituent elements. As with other forms of interpersonal violence, elder abuse is an unpalatable taboo subject often shrouded in secrecy and shame and can be considered a âhidden problemâ in society (Baker and Heitkemper 2005). However, elder abuse has serious consequences. Apart from the immediate effects of abuse, such as possible bruises, fractures, distress and financial loss (Lindbloom et al. 2007), there are enduring effects such as premature mortality (Lachs et al. 1998), depression and continued psychological distress (Mowlam et al. 2007, Lafferty et al. 2011) as well as a continued experience of fear (Comijs et al. 1998).
In order to provide an assessment of perspectives of elder abuse in our selected countries, this chapter provides a foundation in understanding the topic of elder abuse. As such, it examines issues of old age, the emergence of elder abuse in public discourse, terminological and definitional challenges, prevalence and theoretical frameworks. The reality of elder abuse can differ due to issues of legislative imperatives, mandatory reporting, cultural norms, response systems, policy guidelines and so forth, but this diversity should not be used as a barrier to addressing the topic through a comprehensive, rights based approach.
Old age
The human life cycle has become increasingly demarcated in terms of age-related components as to how an individual is categorised (Boyd and Bee 2004). Old age exists as a definite chronological life stage, but the precise chronological differentiation and meaning of old age can be interpreted differently (Posner 1996, Katz 1996). Consequently, although chronology can be the primary reference for old age, ageing theories are also influential when considering the ageing process itself (WHO 2002a; UN 2004).
The modern classification of older people has reflected Otto von Bismarck's distinction of âthe elderlyâ from the general population (Carp 2000) by introducing in the late ninteenth century rudimentary pensions for those over 65 years of age as a reaction to a rising interest in socialism in Germany. Subsequently, âover 65 yearsâ became acknowledged in many Western countries as the demarcation of the category âolder personâ. For example, 65 years of age is frequently acknowledged as the age of retirement and is employed when calculating age dependency ratios. Older age dependency ratios are based on the number of older people (generally 65 years and older) compared to the number of people of working age (i.e. 15â64 years of age). Projected population statistics suggest that the old age dependency ratios in Europe may double in the next forty years (Lanzieri 2006). However, with increasing dependency ratios, the age of retirement has risen moderately in some countries (WHO 2011, Phelan 2011) with some commentators lobbying for further increases to 70 years of age (Economist 2011).
Other age references must also be acknowledged; for example, the WHO (2002a, 2011) and the UN (2004) both use the standard of 60 years to describe âolder peopleâ. The WHO (2002a) argues that, although the marker of 60 years may appear young, in the developed world and in the developing world, chronological age is not a precise indicator of the changes that accompany ageing. In addition, increased complexity has occurred in classifying older age to subgroups of young old and older old (see Neugarten's 1974 seminal work). The most remarkable demographic increase in older people has been within the older old age group (UN 2004) who are more vulnerable to elder abuse (O'Keeffe et al. 2007, Naughton et al. 2010). As the population of older people increases globally, elder abuse has the potential to increase and thus it is imperative to understand this social challenge so that preventative and ameliorative activities may be implemented within all levels of society from cultural unacceptability to proactive government policy and practice.
Ageism
Ageism has been highlighted as an underlying factor in the emergence of elder abuse (Brandl et al. 2007, Phelan 2008). An examination of elder abuse using an ageist lens has the advantage of incorporating structural, political and social contexts (Kingston and Penhale 1995, Harbison 1999). Ageist attitudes contribute to the non-identification and non-recognition of elder maltreatment as well as the passive tolerance of abuse of older people. First identified in 1969 (Butler 1969), ageism is a relatively new socially constructed concept and can be defined as the systematic stereotyping and discrimination of older people due to their age (Pickering 2001). This may be accompanied by a failure to reflect individualism and a high valuation on youth (Harbison 1999). Ageism may also encompass an obstruction to social participation (Solem 2005) and covertly support the value given to youthfulness and a âculturally endemic paranoiaâ of ageing (Schwaiger 2006: 14).
Ageism is an important factor in considering elder abuse in the context of healthcare settings (Herdman 2002). The health system, as an institution of society, may reflect ageist assumptions of society, which can be introjected into healthcare workersâ professional activities (Garner 2004). Ageist attitudes of healthcare staff are important contributors to deficient care of older people. Thus, in preventing elder abuse, confronting ageist attitudes is considered central to responding to the perpetration of elder abuse (Biggs et al. 1995, CHI 2002, Phelan 2008).
Theories of the social construction of old age and political economy perspective on elder abuse are based broadly on the concept of ageism and consider the position of an older person in the social and political environment of contemporary Western society. The social construction of ageing considers issues such as how ageing is constituted in society and the challenges faced by an older person in his or her everyday existence. Advocates of the political economy perspective focus on challenges experienced due to age and the contribution of public policy to these challenges and how such policy interprets social problems. For instance, the application of welfarism, in terms of pensions and other benefits for older persons, presupposes financial dependency. Thus, ageism is one consequence of the division of labour and social inequalities rather than as a result of the ageing process per se (Angus and Reeve 2006, Roscigno et al. 2007, Phelan 2008). Society imposes an artificial dependency on older people through mandatory retirement, which restricts the role of older people in society and enforces poverty on them as retirement pensions are not generally linked to industrial wages. Thus, as Biggs et al. (1995) note, abuse can arise covertly from society due to the marginalisation and disempowerment of older people. The political economy perspective gives credence to the idea that wider societal structures influence elder abuse. However, this approach provides limited insight into the micro-environment of dyadic abuse. Moreover, studies recording elder abuse in countries where old age is valued (Kosberg et al. 2003), such as Japan, militate against ageism as an explanatory framework for elder abuse.
The issue of power relations has also been the focus of elder abuse research. The passivity of older people can occur as they accept their situation of powerlessness and resign themselves to this situation as part of âbeing oldâ, thus normalising and internalising the ageist care practices (Minichiello et al. 2002). However, Podnieks (1995) argues that powerlessness is not a central issue for abused older people and proposes that older people in the abusive context develop a âhardinessâ which they use to adapt to the experienced mistreatment. Value judgements regarding older people can underpin tolerance of elder abuse, whereas identical abuse in a child context would be a cause of concern. The abuse may also be justified by seeing the older person as causing the negative action. This perspective of blaming the victim is supported by terminology and perceptions such as seeing older people as âburdensâ and lacking function in society.
Tracing the history of elder abuse
Elder abuse is a component of the family violence spectrum, which also includes domestic violence and child protection. Like child protection, elder abuse emerged in the domain of medicine when Baker (1975) and Burston (1975) both published in scientific journals about the physical abuse of older women. This does not mean that elder abuse did not occur prior to 1975, but, rather, it was not recognised as a distinct phenomenon. For instance, in popular mythology and ancient folklore, there are tales which describe particular practices, such as the abandonment of old people in the woods for being non-productive and, therefore, a burden on the family (Reinharz 1986, Carp 2000). The treatment of older people has also been bound up with the history of the poor (Means and Smith 1998), for example in relation to the Poor Laws from 1563 onwards (Driver 2008). Consequently, various forms of abuse have been supported as norms within interpersonal relationships with a notable societal transformation in attitudes following formal recognition of abuse (Biggs et al. 1995).
Formal recognition of elder abuse has stimulated an interest in the areas of legislature, health and social care to a varying degree within differing countries. Although the âdiscoveryâ of elder abuse was in the United Kingdom, most of the subsequent proactive activities occurred initially in the United States, Canada and Australia. For example, âelder abuseâ was first used in congressional hearings in the United States (US) in the late 1970s by the House Select Committee on Aging, also known as the Pepper Commission (Wallace 2003), although the history of adult protective services in the United States can be traced back to 1958 when the National Council on Aging convened an informal committee of social workers due to concerns regarding the growing number of incapacitated and socially isolated older people with inappropriate care-givers (Mixon 1995). In contemporary society, elder abuse is a significant global concern with a defined focus in the context of international agencies (WHO 2011). However, the complexity of elder abuse is apparent in difficulties such as disclosure, the reality of reduced (due to death or illness) or enforced (by the perpetrator) social networks, and the inability to recognise the abuse due to socially acceptable norms. Moreover, unlike younger age groups, time is not on the older person's side, and, often, elder abuse can be complicated by physical and cognitive challenges as well as a fear of transfer to residential care.
Terminology
Early articulations of elder abuse presented fundamental limitations and, similar to the terminological quagmire of child protection (Kempe et al. 1962), were heavily influenced by a medicalised lens. Initial terms such as âgranny bashingâ (Baker 1975), âgranny batteringâ, (Burston 1975) and âgranny abuseâ (Eastman 1988) inferred a clear gender distinction and privileged physical abuse of older people. Acknowledging a need for gender neutral terminology, Block and Sinnott (1979) used the term âbattered older person syndromeâ, which also implied physical abuse, and medicalised elder abuse by suggesting a group of related symptoms.
The debate on terminology has been contentious and not always acceptable to all professionals or scholars (Wallace 2003). Macdonald (1997: 414), for example, views the term elder abuse as a âhorrific phraseâ stating that the real issue should be on the abusive act perpetrated against a vulnerable person regardless of age. Johnson (1986) argues that the term âelder abuseâ is a tautological trap as the term is used to both name the phenomenon and define it, which results in confusion rather than clarification. Furthermore, feminist objections have focused on the gender neutral term of elder abuse, with claims that this neglects to acknowledge the gendered nature of attitudes, expectations and behaviour in elder abuse. Neysmith (1995), for example, argues that the term elder abuse does not make a distinction of how older women's experiences of abuse may differ to those of older men.
A proposed solution to address the terminological problems of elder abuse was to replace the terms âabuseâ and âneglectâ with less incriminating, non-judgemental ones such as âmistreatmentâ and âinadequate careâ (Quinn and Tomita 1997) or adult protection or protection for vulnerable adults (Brammer and Biggs 1998). However, different terminology, such as that cited above, does not appear to be less accusatory or does not resolve the complexity of definitional difficulty (Carp 2000).
Other terminological concerns have focused on the interpretation of neglect within elder abuse. While neglect, as a distinct phenomenon, has often been mentioned in abuse definitions (Krug et al. 2002), it has been analysed to a much lesser extent (Bennett et al. 1997). A further complicating issue is the uncertainty regarding neglect by omission (passive) or commission (active). Such uncertainty regarding the position of neglect is also reflected in various approaches to self-neglect, which is also termed Diogenes Syndrome or Senile Breakdown Syndrome. Self-neglect, as defined by Pavlou and Lachs (2006), is the profound inattention to hygiene or health due to an inability, unwillingness or both to access potentially ameliorative services. Self-neglect in older people may be due to lifestyle choices and personality traits and is not necessarily related to a psychiatric disorder (Reyes-Ortiz 2001). In the United States, self-neglect is considered under the term elder abuse and constitutes the highest ranking referral issue in adult protective services (Pavlik et al. 2001). This contrasts with countries such as Ireland and the United Kingdom where self-neglect is not considered the remit of elder abuse activities although in Ireland the Health Service Executive (HSE 2012) has recommended that cases of serious self-neglect are handled according to the general elder abuse guidelines. Consequently, due to this dual interpretation of the term neglect, standardised understanding of elder abuse appears to have been further hindered.
Definition
Defining elder abuse has been a contentious issue (Bonnie and Wallace 2003, Fulmer et al. 2011). Some fundamental elements such as environmental factors (elder abuse in the home or institution) and basic types (physical, psychological, sexual, or financial abuse and neglect) are generally agreed upon but difficulties present beyond this point. Further exacerbating issues are the differences in definitions between older people, carers and professionals, such as healthcare workers (Mowlam et al. 2007). Depending on the definitional source, the emphasis can change, yet each of these sources claim an elder abuse definition based on the âobjective statement of factâ (Brammer and Biggs 1998: 301). Definitions are also complicated by complex interpersonal relationships, a lack of discrimination between interpersonal conflict and abuse, and scant atte...
