Promoting Informed Action. Introduction. Definition of elder abuse SUBJECT: ELDER ABUSE

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1 .# Promoting Informed Action SUBJECT: ELDER ABUSE IN COOPERATION WITH: DENISE GAGNÉ, DIRECTION RÉGIONALE DE SANTÉ PUBLIQUE DE LA CAPITALE-NATIONALE MAXINE LITHWICK, CLSC RENÉ-CASSIN DIANE MARTEL, DIRECTION RÉGIONALE DE SANTÉ PUBLIQUE DE MONTRÉAL Introduction For many people in our society, old age is synonymous with dependency, vulnerability, illness, uselessness, lack of productivity, inaction and isolation. 1,2 Older adults are often considered a burden for their family and society as a whole. However, the elderly are far from forming a homogeneous group and their situation is nowhere near as deplorable as one might think. 3 In fact, many seniors describe their health as good to excellent, say they face few or no limits on what they can do, have high morale and do not feel isolated. 3 We have a tendency to protect older adults in the same way we do children. This attitude, which is sometimes taken to extremes, reflects a general malaise with respect to old age and aging that often stems partly from a lack of knowledge in this regard. Elder abuse, for example, is one area in which knowledge is insufficient. Even though interveners are quite familiar with this social problem, it only recently caught the attention of public health officials and is still a fairly new field of research. 4 Definition of elder abuse There is a lack of consensus on how to define the problem of elder abuse. In fact, there are almost as many definitions as there are authors, professions, perspectives and interests that focus on it. 4 Some people equate the phenomenon with violence and assault, while others consider it a form of mistreatment or exploitation. Whatever, the case, it is generally recognized that there are four types of elder abuse: material or financial abuse, psychological abuse, physical abuse and neglect. Denial or infringement of rights is sometimes considered a fifth type of elder abuse. Centre québécois de ressources en promotion Page 1 of 10

2 Material abuse. Material or financial abuse is the most common type of abuse of older adults, accounting for over 50% of cases. 5 It includes behaviour such as manipulating victims to obtain money, harassing them, using coercion or fraud to control their money or property, using one's influence to make them change their wills and attempting to usurp their property rights. 3,5 It also includes stealing victims' property, managing their property inadequately or abusing one's power of attorney. 5 Even though material abuse is the most common form of elder abuse, it is the one that older adults most minimize or most systematically refuse to report to the authorities. It is also the form that professionals take into account the least often. 5 Psychological abuse. Psychological abuse is often referred to by other names such as emotional or social abuse, chronic verbal abuse or mental cruelty. Regardless of the term used, this type of abuse mainly takes the form of verbal insults and threats. 3 Physical abuse. Physical abuse includes all types of physical mistreatment, even if do not leave any physical traces, such as pushing, hitting, forcible confinement and threats of physical violence. 2,5 Sexual assaults can also be assigned to this category. Such assaults include all acts of a sexual nature that are performed on a person against his or her will. Active and passive neglect or self-neglect. Neglect and self-neglect are the least well-documented forms of elder abuse. 5 Passive neglect is defined as the involuntary failure to fulfill functions aimed at ensuring an older adult's well-being (e.g. often forgetting to give the person his or her medication), while active negligence involves a conscious decision on the part of a caregiver to not meet an older adult's essential needs. 3 As for self-neglect, it involves situations where mentally competent older adults refuse to accept solutions proposed by social workers or medical personnel that might be of benefit to them. 5 Denial or infringement of rights. Denial or infringement of rights consists in violating a person's rights and freedoms. 2 This form of abuse includes failing to respect a person's privacy, private life, dignity, freedom and autonomy as well as interfering with their enjoyment of property or freedom to use it, and with their integrity, safety and right to equality. 2,5 For example, it involves subjecting patients to treatments without their consent or to unjustified forcible confinement, force-feeding, put-downs, infantilization, depersonalization and discrimination, or refusing to entrust their personal care to a person of the same gender. 2,5 Certain types of abuse, such as financial abuse, target the elderly more specifically. 4 Moreover, when older adults are victims of domestic or family violence, they are often victimized differently from people in other age groups. 5 For example, seniors subjected to abusive behaviour by members of their own family seem to be less likely to denounce their abusers and reveal the crimes of which they have been victims. 5 Various factors are put forward to explain this failure to denounce abusers: 2,4,5,7 Centre québécois de ressources en promotion Page 2 of 10

3 Solitude Being cut off from the rest of society Dependency due to disabilities Fear of abandonment Living in an institution or being afraid of being sent to one Lack of police involvement Lack of resources for helping older adults. Fear of reprisals or of creating problems for one's children Desire to protect the privacy of one's family Feelings of shame and guilt Concern that legal proceedings will be more complicated than maintaining the status quo Profile of victims and abusers There is no unanimity as to who should be included in the "older adult" category. According to some, it should comprise people aged 55 and over, while others claim it should be reserved for people aged 60 or 65 and over. 5 In Québec alone, people 65 and over numbered in 1986, in 1991 and more than a million in It is estimated that they will reach 2.2 million in a The elderly thus represent a growing segment of Québec society. Although elder abuse knows no sociodemographic boundaries, it seems to affect certain segments of the population more than others. 2,3 For example, victims of material or financial abuse tend to be widows, live alone and receive less help if they are sick or disabled. 3 As for abusers, they are usually friends, neighbours, acquaintances or distant relatives who have the opportunity to act, need money, are inclined to exploit other people financially or feel they are entitled to the property they desire. 3,8 Many abusers also have physical, emotional, alcohol or drug problems. 3 Psychological abuse occurs most often in troubled, long-term marital or filial relationships. 3,5 Most victims are married to and live with the abuser and tend to blame themselves for the abuse 3. Older adults are victims of physical abuse less often than are members of the general population. 5 As a rule, the abuse is perpetrated within the family by a spouse or another immediate family member, generally a son or a daughter. 5 Men are exposed to a greater extent than women to physical abuse as they age, but women are more likely to suffer serious physical abuse. 3,4 Victims of neglect are usually women, widows, people who have a physical disability and are thus dependent on others for doing certain activities or people who consider themselves to be in poor health. 3 They are usually abused by a member of their immediate family or by a caregiver. 3 Victims of a For more information, see the population data on the Web site of the Ministère de la Santé et des Services sociaux du Québec: Centre québécois de ressources en promotion Page 3 of 10

4 denial of rights are usually older adults living in long-term care facilities or suffering from the final stages of a terminal illness. 5 For the most part, their abusers are members of the health-care staff. 5 Scope of the problem in Québec and Canada The scope of the problem of elder abuse is not very well known. There are almost no data on its incidence, b and while a few studies deal with its prevalence, c the use of their data is limited by methodological considerations. 4 A survey of 2008 respondents in Canada found that 4% of older adults who live at home are victims of some form of abuse (physical assaults, chronic verbal abuse, financial abuse or neglect) after the age of 65 (the proportion is the same in Québec). 3 Roughly one respondent in five reported that they had been subjected to multiple forms of abuse. The General Social Survey conducted by Statistics Canada in 1999, which interviewed 4324 respondents aged 65 and over living in private dwellings, considered four categories of elder abuse, namely, psychological abuse, financial abuse, acts of violence and sexual assault, inflicted by grownup children, spouses or informal caregivers during the five years preceding the survey. 10 One percent (1%) of the respondents said that they had been victims of acts of violence, sexual assault or financial abuse, while 7% declared that they had suffered psychological abuse. Apart from these population surveys, the vast majority of research on elder abuse has been carried out with professionals who work with the elderly. 4 While such research confirms the existence of this type of abuse, it provides little information on its prevalence. Nonetheless, certain local data provided by CLSCs indicate that between 7% and 18% of seniors are victims of abuse, depending on the sector (prevalence among elderly clients of home support services). 4 Scope of the problem elsewhere Two population studies conducted in the United States found prevalence rates of 1% and 3.2% respectively for abuse of older adults. 4 In addition, a survey of professionals in U.S. institutions concluded that between 36% and 81% of these interveners had witnessed elder abuse (in Canada, the rate varies from 25% to 84%). b Incidence: number of new cases in a given period in a given population. c Prevalence: number of victims in a given population, with no distinction between new and old cases. Centre québécois de ressources en promotion Page 4 of 10

5 Places where elder abuse occurs In Canada, over 90% of seniors live in private housing, i.e. their own dwelling or that of a relative. 3 The remaining 10% live in some form of institution (hospital, nursing home, long-term care centre, etc.). Abuse is encountered in all of these environments. Risk factors Abuse is associated with a range of risk factors, as shown by the following list: 4 Personal factors Age (risk increases with age) Low level of education (being shunted aside, poor knowledge of one's rights, low income) Ethnic background and language (linguistic barriers, isolation) Poor physical health, being limited in daily activities, loss of autonomy Personality, attitudes (selflessness, resignation) and beliefs Lifestyle (alcoholism, accumulating money at home, routine comings and goings) Behaviours that are difficult for caregivers to cope with (incontinence, aggressivity) Dependency of the victim (the victim is dependent on others to satisfy his or her needs) Dependency of the abuser (the abuser is more financially dependent than his or her victim) Dissatisfaction with life (the victim is unhappy and wants to die) Factors related to older adults' immediate life setting A history of abuse in their life setting Civil status (increased risk among married couples and people living with their spouse) Characteristics of the caregiver (a family member who lives with the older adult, has been a victim of abuse, is dependent, lacks personal resources or has a psychiatric or drinking problem; a caregiver who is suffering from burnout or has a conflictual relationship with the patient) Older adult-caregiver relationship (the older adult is being looked after by an incompetent, exhausted, unscrupulous or ill-intentioned caregiver) Poor conditions in family or institutional settings (difficult working conditions, inadequate housing, lack of privacy, isolation, work-related stress) Special situations (seniors with disabilities living in rural or remote regions or in Native or ethnocultural communities) Centre québécois de ressources en promotion Page 5 of 10

6 Factors related to older adults' social network Social isolation (lack of contact with other people, lack of people to confide in or turn to when necessary, lack of a support network because of mental state, poverty, alcoholism, drug addiction, communication problems, etc.) Factors related to social conditions Budget cuts, denial of seniors' problems and needs, lack of resources, administrative regulations, inadequate government policies, etc. Factors related to dominant norms, values and ideologies Tolerance within society towards omnipresent violence Erroneous beliefs and poor understanding of the aging process Dominant values within society (youth, productivity, independence) These factors are part of a phenomenon known as "ageism," which includes all negative attitudes and prejudices towards aging and the elderly. 2 Consequences of elder abuse In general, victims of elder abuse have a different perception of this phenomenon than professionals do. More specifically, they tend to dedramatize the abuse to which they have been subjected. 4 It is known, however, that elder abuse leads to a host of physical and psychological problems in the form of depression, stress, indifference, loss of hope for the future, physical injuries, sleeping and eating disorders, hospitalization, placement in institutions and death. 3,4 Effective strategies for preventing elder abuse or promoting solutions Strategies for preventing elder abuse or promoting solutions can be grouped into three main categories. Actions aimed at preventing the problem from arising Early detection Actions aimed at reducing or eliminating elder abuse when it is detected Regardless of the category they belong to, all strategies must involve joint action by all sectors concerned by the problem of elder abuse (health, justice, public safety, non-governmental organizations, etc.). Centre québécois de ressources en promotion Page 6 of 10

7 Actions aimed at preventing the problem from arising To date, the strategies used to prevent elder abuse have varied, involving educational, political and legislative approaches as well as services for seniors. The type of strategy selected depends on the setting. 3,4 Educational approach. This approach involves informing and raising awareness among the general public in an effort to eliminate prejudices, improve people's perception of aging and make seniors' needs better known. Older adults must be informed of what factors make them more vulnerable to abuse and what community services are available as far as their rights, finances and social needs are concerned. In addition, formal and informal caregivers and professionals from key sectors (police, lawyers, bankers) must be provided with the means they need to foster prevention and establish intervention programs. Seniors are in favour of this kind of approach. 7 Political approach. This approach involves intervening over the long term in regard to the sociocultural causes of abuse by attempting to eradicate sexual inequality, delegitimize abuse and extend government powers to family matters. Action in this field can be taken by lobby groups who give themselves a mandate to have laws or policies concerning older adults adopted, abolished or changed. Seniors can also make a direct contribution by getting involved in the various levels of government. In general, this type of approach is aimed at increasing respect for the elderly. Legislative approach. d This approach involves reviewing, amending or adopting laws and regulations to protect older adults. Services approach. This approach involves providing the elderly with a range of services that help them to maintain their autonomy, including counselling, support groups, emergency shelters, medical and legal services, housekeeping services, meals-on-wheels, adequate transportation, emergency phone service and respite services for caregivers. Early detection of elder abuse This strategy is aimed at identifying older adults who are being abused and at offering them early treatment. 4 Questionnaires exist for assessing the probability and severity of abuse. For example, the Caregiver Abuse Screen for the Elderly (CASE) and the Brief Abuse Screening for the Elderly (BASE) are two questionnaires designed to identify seniors who are being mistreated by informal caregivers. Crisis lines are also useful for detecting cases of abuse and taking immediate action. All interveners in the health network, community organizations, volunteer organizations, police forces, financial or legal institutions and so forth must be able to detect abuse among the seniors they meet. d For more information, see the literature survey by Poirier and Poirier, which looks at the various codes, laws and regulations in force in Canada for addressing the problem of elder abuse. 5 Also see the study put out by the Commission des droits de la personne et de la jeunesse, which takes stock of the different legislative, regulatory, social and community systems designed to protect older adults. 2 Centre québécois de ressources en promotion Page 7 of 10

8 When abuse is found or suspected, the parties concerned should be directed to the appropriate agencies. For this purpose, information, awareness-raising and training activities should be organized on the problem of elder abuse, available resources and appropriate interventions. Actions aimed at reducing or eliminating elder abuse when it is detected The objective here is to put a stop to the mistreatment of older adults or to mitigate its effects once it has been detected. Various models are proposed below to achieve this goal. 4 Family violence model. This intervention strategy does not focus on the causes of the abuse but rather on its symptoms and allows action to be taken rapidly over the short term. Symptoms of abuse may be dealt with through protection orders or by offering victims access to support groups, empowerment approaches, victims' aid, compensation or monitoring programs, and so forth, etc. Adult protection model. This model, like the child protection model, favours mandatory reporting of elder abuse. Already implemented in the Atlantic Provinces, it must be used with caution, however, because it has certain disadvantages. Indeed, it tends to infantilize seniors by viewing them as lacking autonomy, often leads to seniors being removed from their life setting, and is totally ineffective at addressing financial abuse, the most common form of elder abuse. 5 Nevertheless, the vast majority of older respondents who participated in a Québec study said they were in favour of this type of measure. 7 Victim assistance model. This model strives to teach victims to defend their rights and achieve personal goals. Multidisciplinary model. This model provides front-line interveners with access to multidisciplinary advisory teams specialized in elder abuse. Such teams can study cases, give advice on what solutions should be applied, take action, and so forth. Family systems model. This model is aimed at readjusting family dynamics without trying to lay blame on particular individuals. It proposes long-term interventions. Any of the aforementioned approaches, or combination of them, may be used depending on the circumstances. In choosing an approach, one must take into account the victims' needs and expectations, their ability to look after themselves and their property, their life setting, and the ties they would like to maintain (in cases where the abuser is the caregiver). Sometimes, abusers must also be offered support when they are caregivers suffering from exhaustion. Since cases of elder abuse are often complex and require legal, judicial, psychosocial and medical action, interveners may need access to the following resources: specialized professional support, multidisciplinary case conferences, consultation committees, committees of experts, and so forth. Centre québécois de ressources en promotion Page 8 of 10

9 Specific evaluation tools The effectiveness of the various intervention strategies presented above remains to be demonstrated, as few interventions have been evaluated scientifically to date. 4 Indeed, any assessments that have been done thus far have often measured the effectiveness of interventions on the basis of interveners' opinions, which is not a valid criteria since interveners often view elder abuse and actions taken to address it differently than do seniors who are victims of such abuse. 4 Certain evaluation problems also stem from the fact that there are no objective measures of success. 4 Therefore, work remains to be done to assess the effectiveness of intervention strategies. Specific prevention and intervention tools Links to prevention and intervention tools concerned with elder abuse. Web sites Links to interesting Web sites on elder abuse. Centre québécois de ressources en promotion Page 9 of 10

10 References 1. Langlois, M. (April 2003). La FADOQ : un maillon de la chaîne pour contrer la violence envers les aînés. Montréal: Fédération de l'âge d'or du Québec. Presented at the Conférence québécoise sur la violence envers les aînés : agir en collectivité. [ PDF file ] 2. Bernard, C. & Ledoyen, A. (2001). L exploitation des personnes âgées : vers un filet de protection resserré. Rapport de consultation et recommandations. Québec: Commission des droits de la personne et des droits de la jeunesse. 3. Podnieks, E., Pillemer, K. & al. (1990). National Survey on Abuse of the Elderly in Canada. Toronto: Ryerson Polytechnical Institute. 4. Martel, D. (1996). La violence envers les gens âgés. Recension des écrits. Montréal: Régie régionale de la santé et des services sociaux de Montréal-Centre, Direction de la santé publique. 5. Poirier, D. & Poirier, N. (1999). Why is it so difficult to combat elder abuse and, in particular, financial exploitation of the elderly? Moncton, submitted to the Law Commission of Canada. 6. Léger et Léger Recherche et Stratégie Marketing (1998). Étude auprès des personnes âgées de plus de 50 ans sur leurs attitudes et leurs besoins en matière d informations juridiques. Résultats de la recherche quantitative. Montréal: Commission des Services Juridiques. 7. Léger et Léger Recherche et Stratégie Marketing (1998). Perceptions des personnes âgées à l égard de la violence. Résultats de la recherche qualitative. Montréal: Commission des Services Juridiques. 8. Spencer, C. (1996). Diminishing Returns. An Examination of Financial Responsibility, Decision- Making and Financial Abuse among Older Adults in British Columbia. Vancouver: Gerontology Research Centre, Simon Fraser University. Cited in Poirier, D. & Poirier, N. (1999). Why is it so difficult to combat elder abuse and, in particular, financial exploitation of the elderly? Moncton, submitted to the Law Commission of Canada. 9. Kozak, J. F., Emslie, T. & Verdon, J. (1995). Perspectives épidémiologiques des mauvais traitements et de la négligence à l endroit des personnes âgées : revue des textes de recherche nationale et internationale (pp ). In Mauvais traitements auprès des personnes âgées : stratégies de changement. Éditions Saint-Martin. Cited in Martel, D. (1996). La violence envers les gens âgés. Recension des écrits. Montréal: Régie régionale de la santé et des services sociaux de Montréal-Centre, Direction de la santé publique. 10. Statistics Canada (2000). Family violence in Canada: A Statistical Profile Ottawa: Canadian Centre for Justice Statistics. Written by: Amélie Bourret, February 2005 Revised by: Marie-Ève Lemieux Breton, February 2006 Centre québécois de ressources en promotion Page 10 of 10