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Elder abuse conceptually is recognizable by most scholars of gerontological, elder law, and elder policy undertakings. It is so important that in almost every jurisdiction, especially in advanced societies, it has evolved into a topic of great relevance along with the rapid population aging. The roots of a general aversion to almost universal prohibition of acts of elder abuse do not always translate into societal and individual actions which would be categorized within the regulatory, ethical, legal, and societal concepts of what is generally classiﬁed as some level of elder abuse. In its obvious forms which generally fall within the construct of physical abuse, it is often self-evident to all observers that elder abuse has occurred. There are many instances of elder abuse that are less self-evident and more subtle that are also identiﬁed and construed as elder abuse. These too must be addressed at all levels of society in order to achieve respect for elders and promotion of their quality of life and dignity. This review should help explore the range of deﬁnitions, the categories that commonly exist, and the manifestations of elder abuse across a range of societies including those that formally prohibit its existence while acknowledging its existence.
One of the miracles of modern medicine, combined with public health measures and the creation of safer cities and more secure supplies of food and all other necessities of life, is increasing longevity. In all developed and developing world countries, life expectancy at birth has increased. In Western countries, the issue of the aging of the population has reached the point of being deemed by many as one of the great societal challenges of the next few decades. With increasing longevity comes many positive attributes, including the postponement of many disabling medical conditions and, when they exist, reasonable control of them so that it appears that many of even the frail elderly can experience a modicum of enjoyment and quality of life into their later years.
One of the sad commentaries on this otherwise increasingly successful aging experience is the continued existence of elder abuse in all its formulations: at the individual level, physical, emotional, and ﬁnancial abuse and, at the macro level, societal manifestations of abuse. In most jurisdictions there are now formulas and approaches to recognizing elder abuse where it exists, undertakings to educate the public, health and social service, and legal professionals as to the risk factors and indicators of abuse. In concert with these educational efforts, there are a range of attempts through legal and regulatory measures to identify abuse and take steps to thwart elder abuse, to protect the elder on the receiving end of the abuse, and to mete out punishment to those acting in an abusive manner.
The exploration of the issue of elder abuse from the ethical perspective should provide important insights and lessons that can be incorporated into the personal lives and professional practice of all those interested in and dedicated to the elimination of elder abuse in all its forms.
History And Development
Incidences of elder abuse have been recorded in literature, rites, folklore, and theater from antiquity to modern times. Among the earliest recordings of elder abuse are the Greek creation myths, where two generations of rebellious sons violently overthrew and exiled their fathers for dominion over earth (Reinharz 1986). Sociologists claimed that the ancient Greeks, similar to their gods, treated their elders with disrespect and neglect (Reinharz 1986). Studies into other ancient cultures have documented various forms of elder abuse, including euthanasia of aging kings and priests to prevent the people from falling to ruin caused by the leadership of an incompetent (Reinharz 1986). Russian folklore tells of a ﬁnal rite of passage where old people were taken on a sled and abandoned in the forest (Puchkov and Damzaev 2007).
Paradoxically, elders have been held in high esteem by many cultures, and respect for elders is referenced in many historical texts, including Islamic, biblical, and Russian texts (Puchkov and Damzaev 2007). Still, in early modern Western times, a disproportionate number of older women were victims of the witchcraft craze during the sixteenth and seventeenth centuries (Stearns 1986). Men over 50 were the most frequent murder victims in France during the eighteenth century (Stearns 1986). Conﬂict over property rights, strain on family resources, and the inhibition of younger kin’s aspirations were all motivations contributing to these two forms of elder abuse (Stearns 1986). In the nineteenth century, the impoverished elderly, some of whom had been cast out by their families, dominated almshouses and hospitals (Stearns 1986). During the nineteenth and twentieth centuries, there was a paucity of substantive evidence of elder abuse (Stearns 1986). This was perhaps due to increasing retirement support and increasing residential separation between generations leading to decreased abuse, or it would be due to less reporting from elders and communities (Stearns 1986). Elder abuse resurfaced in the 1970s and early 1980s as what was colloquially called “granny battering” (World Health Organization (WHO) 2002). The public was shocked and outraged by this “new” form of domestic violence (WHO 2002). Elder abuse has since gained increasing public attention and concern in recent years.
Many organizations have deﬁned elder abuse, with similarities and differences among the deﬁnitions. The World Health Organization (WHO) and nonproﬁt and governmental organizations from Australia, Canada, India, and the United States all incorporate similar elements in their deﬁnition of elder abuse: an action or behavior, or a lack of action or behavior, that is done to an older person in a relationship of trust or legal obligation, which causes actual harm/distress or risk of harm (WHO 2002; Australian Network for the Prevention of Elder Abuse (ANPEA) 1999; National Initiative for the Care of the Elderly (NICE) 2005; HelpAge India 2013; National Committee for the Prevention of Elder Abuse (NCPEA) 2008). However, there are variations from country to country. For example, some do not include a lack of action, and others do not include a trust relationship (ANPEA 1999; NCPEA 2008).
Most of the abovementioned organizations and agencies involved in the documentation and tracking of elder abuse list physical, psychological, sexual, and ﬁnancial abuse and neglect as categories of elder abuse (WHO 2002; ANPEA 1999; NICE 2005; HelpAge India 2013; NCPEA 2008). Interestingly, certain agencies and organizations list a variety of extra categories, such as abandonment, social abuse, and disrespect (WHO 2002; ANPEA 1999; HelpAge 2013).
However, the general public may not recognize elder abuse in the broadly deﬁned manner discussed above. Studies suggest that many people relate abuse to violent behavior, but not neglect or abandonment, and categorize disrespect and lack of digniﬁed living as maltreatment (WHO 2002).
In addition to variances in deﬁnitions of “abuse” in this context, there are also variances in the definition of “elder” and in the approaches used to measure incidence rates. For example, some studies include adults aged 60 and over, while others focus on adults over the age of 65. Some incidence reports are based on self-reporting by older adults via questionnaires and polls, whereas others are based on data gathered from health-care providers, police, and other stakeholders.
Regardless of all the above-referenced regional discrepancies in classiﬁcation, elder abuse is broadly understood to refer to some form of mistreatment of an older person through an act or omission in any public or private sphere.
Legal Dimensions As A Reflection Of Ethical Concern
Most jurisdictions have enacted legislation, whether national, state, provincial, or municipal, that addresses the issue of elder abuse, either directly or indirectly. In many jurisdictions, laws of general intent may assist with the protection of individual rights, or of the rights of vulnerable people, which can indirectly prevent or address elder abuse, even if the laws do not speciﬁcally target elder abuse (Law Commission of Ontario 2012).
Issues of human rights for older persons were developed by the United Nations in 1991 in the formulation of the Principles for Older Persons, which provided guidance to member countries on independence, participation, care, self-fulﬁllment, and dignity, and in the 2002 Madrid International Plan of Action on Ageing which aims to ensure that older adults in all countries are able to age with security and dignity (United Nations (UN) 1991, 2002). These principles and action plans have arguably informed much of the evolving global awareness of the issues facing older adults and the corresponding legal initiatives to address elder abuse.
Developed countries are now increasingly enacting legislation to address or remedy elder abuse, speciﬁcally. Legal approaches to addressing elder abuse are usually driven by and supplemented with broader, multidisciplinary approaches, such as formal and informal education, legislation, and government and nonproﬁt organization-led programs and services. Despite these preventative measures, elder abuse remains an ongoing social phenomenon. Prevalence rates or estimates exist only in developed countries that collect such data, and, according to the WHO, most of the data gathered in this regard comes from the United Kingdom and Canada, which report incidence rates ranging from 1 % to 10 % (WHO 2002). Notably, all countries report that the perpetrators of abuse are most likely to be family members, in particular adult children.
There are many challenges in recognizing, preventing, and prosecuting elder abuse. Misinformed assumptions about older adults and the deﬁnition of elder abuse will often interfere with society’s ability to recognize the various forms of elder abuse as “elder abuse.” Consequently, instances of elder abuse, especially those that take place in family units or in institutional settings, tend to be more readily framed as relationship problems, labor force issues, or quality control issues. Laws that are intended to protect older adults from abuse must be balanced with laws that protect their autonomy, and in some instances this balancing act may actually provide narrow windows of opportunity for abuse. Adjusting the balance is therefore imperative, but complicated.
Through discussion of the following examples of various manifestations of elder abuse, it becomes apparent that all countries experience elder abuse and struggle with the challenges inherent in addressing the issue.
Abusive Actions As Reflections Of The Ethics Of Care Or The Principle Of Maleficence (Harm)
Neglect is deﬁned by the WHO, 2002, as an “intentional or unintentional refusal or failure to fulﬁll a caretaking obligation.” Neglect manifests often as a failure to undertake daily tasks, such as housework or meal preparation, when the victim is incapable of doing so for themselves (Action on Elder Abuse 2007). Failure to assist older adults with grooming, toileting, eating, or medication may also be a form of neglect (Action on Elder Abuse 2007). The incidence of neglect increases with age, and more women experienced neglect than men (Action on Elder Abuse 2007). Neglect was mainly perpetuated by partners, family members, and domiciliary care workers (Action on Elder Abuse 2007).
Neglect is not limited to the conﬁnes of familial relationships; residents in care have suffered from forms of neglect such as medication mismanagement, dehydration, malnourishment, and lack of timely care (WHO 2002). These incidents of abuse display ﬂaws in the residential care system. More speciﬁcally, persons capable of reporting these violations may not see them, or regulatory bodies may not appropriately act on the reports of concern, i.e., fear of restriction of trade lawsuits may prevent the regulatory bodies from disclosing these concerns to the public.
Physical abuse is often the most salient form of abuse. It includes inﬂiction of pain or injury such as through slapping or hitting, but it also includes physical coercion and use of inappropriate physical/chemical restraint (WHO 2002). Although physical abuse is clearly immoral and criminal in most jurisdictions, many jurisdictions experience difﬁculty in pressing charges. Like sexual abuse, seniors ﬁnd it difﬁcult to discuss the issue, and often there is denial of the problem (WHO 2002). Some reasons include the victims being ashamed of their situation and the victims wishing to protect their family members from persecution, which especially is the case where the older adult relies on the perpetrator for their care (HelpAge India 2013).
It is generally understood that the incidence of sexual assault among older adults is underreported. Many of older victims of sexual assault are reluctant to report the crime as a result of their feelings of shame and uncertainty as to whether or not they would be believed. This reluctance to report sexual abuse is not particular to older adults, but it may reﬂect societal misconceptions about sexual assault that are speciﬁc to older adults. For example, the pervasive but inaccurate view that sexual assault is a crime of passion, combined with the misinformed notions of diminished sexuality of older adults, may give rise to the assumption that older adults are unlikely to be targets of sexual abuse and that older complainants are simply confused.
Elder ﬁnancial abuse can be broadly deﬁned as the illegal or improper exploitation or use of funds or resources of the older person for the beneﬁt of another. Of note, some stakeholders would include coercion of the older adult to provide free services such as child care in the deﬁnition of elder ﬁnancial abuse. This inconsistency in deﬁnition would serve as an example of the challenges inherent in the broader recognition of elder abuse and could support the notion that elder abuse is vastly underreported as a result of society’s broader inability to recognize elder abuse.
Two common categories of ﬁnancial abuse of older adults are fraudulent schemes perpetrated by strangers who intentionally prey on older adults and the misuse or misappropriation of older adult’s assets by individuals who are known to and trusted by the older adult (Canadian Centre for Elder Law (CCEL) 2013). Fraudulent schemes perpetrated by strangers can include health-care/ insurance fraud, counterfeit prescription drugs, telemarketing and Internet fraud, the refusal to deliver goods or services purchased, and reverse mortgage or equity release scams. These forms of fraud are fairly easy to recognize as ﬁnancial abuse.
A more insidious form of ﬁnancial abuse, and one that can be more difﬁcult to prosecute, is the misuse or misappropriation of assets by someone who is known to (and often related to) the older adult. This form of abuse is prevalent but not always reported because older adults do not wish to see their adult child or caretaker prosecuted (LCO 2012; CCEL 2013). Indeed, much of the case law arising from the misappropriation of older adults’ ﬁnances is generated by litigation that is commenced after the death of the older adult when the beneﬁciaries of the deceased’s estate realize that the older adult’s property was misappropriated during the ﬁnal years of his or her life. Examples of this form of ﬁnancial abuse include the improper exercise of authority under a substitute decision-making scheme such as continuing powers of attorney, misappropriation of funds held in a joint bank account, or the improper transfer, without proper compensation or consent, of the older adult’s interest in real property (CCEL 2013).
Limits On Autonomy As A Manifestation Of Abuse
The erosion of the personal autonomy of older adults can take many forms. Adults are presumed to have decision-making capacity and are therefore afforded autonomy. Cognitive functions may be impeded by biological or medical issues in some people as they age, which can lead people to make assumptions about an older adult’s capacity, or lack thereof. These assumptions can erode an older adult’s ability to access and assert their right to autonomy.
For example, many jurisdictions have enacted legislation that provides for a form of substitute decision making or assisted decision making (LCO 2012; CCEL 2013). The legal documents utilized to establish substitute decision making in some jurisdictions may include restrictive clauses that restrict the authority of the document absent a formal declaration that the older adult is incapable of managing their property (CCEL 2013). However, in practice, the appointed substitute decision makers often rely on informal assessments of capacity (CCEL 2013). The restrictive clause is ignored, as is the legal presumption of capacity (CCEL 2013).
Health care is another realm in which the autonomy of older adults is often overlooked or disregarded. Many jurisdictions have legislation that permits adults to make advance health-care directives – wishes and intentions in writing that are intended to guide the decision making of substitute decision makers in the event that the older adult is no longer capable of managing their health care. However, substitute decision makers and health-care providers in practice may overlook the necessary step of ascertaining the capacity of the older adult and instead simply refer to the advance health-care directive without consulting directly with the older adult.
Another common limitation on the autonomy of older adults arises in the context of personal and sexual expression, especially in communal living environments such as private or publically funded retirement homes or long-term care facilities. It is a fairly common but inaccurate assumption that human sexuality begins at age 19 and stops in middle age. As a result of this misconception, displays of sexuality by older adults in institutional settings may be perceived as displays of sexual deviance. This reluctance to acknowledge sexuality among older adults can have serious consequences, to the extent that public health education, services, and communications may not be offered to older adults living in residential care.
Discrimination And Disrespect As Manifestations Of Elder Abuse
It seems to be a self-evident principle that the common goal of every older adult, and in fact every person, is to age with dignity and respect, free from discrimination and abuse. However, cultural environment is important in understanding abuse in the global context. While many cultures view disrespect as a prevalent form of elder abuse, the actions and behaviors that comprise disrespect and abuse depend on the cultural norms of values and behaviors.
For example, in Chinese culture, younger generations are expected to follow the Confucian tradition of ﬁlial piety. Older generations expect to receive the best possible care as well as obedience, respect, and reverence from younger generations. In a study of Chinese immigrants in Canada, disrespect was found to comprise as follows: the provision of only necessities and nothing for comfort, abrupt and unreasonable commands, dismissive comments, unnecessary scolding or nagging, name calling, lack of communication, space and movement restriction, and being “kicked around” between family members and having no ﬁxed home (Tam and Neysmith 2006).
These examples of disrespect are so culturespeciﬁc that they do not ﬁt into categories of abuse using Western standards. For example, verbal abuse includes scolding or nagging for Chinese elders in addition to yelling and threats (Tam and Neysmith 2006). The use of Western standards of elder abuse, especially in countries of high immigration, may result in a lack of recognition of the detriment these culturally speciﬁc actions are having on the elders of that cultural group (Tam and Neysmith 2006).
Looking to discrimination and disrespect in Western society, older adults are often misperceived as frail, unwell, and prone to negative outcomes. This misconception arises from the opposing association of youth with the future, technology, and life (LCO 2012). Rising from this misperception, old age is used in language as a substitution to mean disadvantage, low income, impairment, and disability (LCO 2012). Furthermore, vulnerability is used interchangeably with the lack of legal decisional capacity (LCO 2012). These inaccurate associations inappropriately classify all older adults into one uniform group that discounts healthy, active, and engaged members (LCO 2012). Use of this language leads to discriminatory attitudes and actions such as paternalism, coercion, and violation of autonomy, privacy, and other rights (LCO 2012). For example, in recent years, the media commonly used terms such as “bed blockers” and the “silver tsunami” to describe older adults. Both terms depict elderly people as a drain on resources, a barrier to younger generations in accessing care, and a threat to the sustainability of the health-care system. Such language can cause the public, health-care practitioners, and older adults themselves to believe that elderly patients should seek out less care and are less deserving of the care provided (LCO 2012).
Women are especially depicted as weak and dependent in society and media, which can reinforce exclusionary practices. In popular culture, use of terms like “crone,” “hag,” and “witch” all contributes to a negative stereotype of older women, which plays into the societal ﬁxation with retaining youth and fear of looking and growing old (LCO 2012).
Throughout human history it appears that the idea of duties of care and respect toward one’s elders appears entrenched in most societies and cultures, whether through religious or societal imperatives. Yet, despite this, it appears that there have always been those that disregard the normative duties and obligations to respect and care for one’s elders: which gets translated into what would be called various formulations of elder abuse.
As the history and contemporary manifestations of elder abuse are studied, it becomes apparent that virtually all societies recognize disrespect and abuse of its elders as unacceptable. Such societies attempt to counter abusive activities through a range of undertakings. These range from very personal, cultural, and religious methods to more pervasive actions such as regulatory and legislative initiatives. In some jurisdictions, the issue is taken seriously enough that there is a willingness to mete out punishments to those that participate in elder abuse. Yet, in many jurisdictions, although elder abuse is frowned upon or prohibited, the actual steps to deal with it, including prohibition and population education, do not always get implemented in a way that successfully eliminates its practice.
Therefore, it seems to be an ongoing human project that includes recognizing the symptoms and signs of possible elder abuse and helping those responsible for education of the population to emphasize and internalize children’s sensitivity to the importance of respect and care toward their elders. Ultimately whatever might drive any inclination to elder abuse would be countered by very strong personal values that would inhibit it. If and when that fails, societies must continue to have regulatory and legislative policies in place to recognize and respond to evidence of abuse that removes the abused elder from the toxic situation and provides some means to regain their position of respect, coupled with their personal dignity and their personal assets that may have been lost during the abusive process.
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