Research Addressing elder abuse: Western Australian case study Blackwell Publishing, Ltd.
Addressing elder abuse
Duncan Boldy, Barbara Horner, Kathy Crouchley and Margaret Davey Freemasons Centre For Research into Aged Care Services, Curtin University of Technology, Perth, Western Australia, Australia
Stephen Boylen WA Office for Seniors Interests and Volunteering, Perth, Western Australia, Australia
Objective: To explore the extent of elder abuse in Western Australia and associated aspects, such as the relationship of the abuser to the victim, risk factors and desirable interventions, and current knowledge and use of relevant protocols. Methods: A mail-out questionnaire was sent to over 1000 organisations and 129 general practitioners (GPs). Recipients were asked to identify any known or suspected cases of elder abuse encountered during the previous 6 months. Results: The estimated prevalence of elder abuse was 0.58% (in individuals 60+ years). Females and those 75 years and older were more at risk than males or those younger. Financial abuse was the most common, and frequently more than one type of abuse was suffered by the same person. The main abusers were adult children or other relatives. Conclusion: The importance of education targeted at professionals, the general public and older people themselves was evident. Important direct interventions identified included respite care, advocacy and counselling. Key words: elder abuse, interventions, risk factors.
1. 2. 3. 4. 5.
An estimate of the prevalence of elder abuse in WA. Relationship of victims to abusers. Risk factors associated with abuse. Desirable interventions. Knowledge and use of current protocols.
To ensure that the views of key stakeholders were taken into account, an Elder Abuse Reference Group was established to oversee the project. This Reference Group consisted of representatives from Advocare Inc., Office of the Public Advocate, Carers WA and Seniors’ Interests.
Method The questionnaire design and content was based on an earlier WA study [4]. During March and April 2002, 1146 questionnaires were mailed to WA recipients of the Curtin University manual ‘Elder Abuse: Protocol and Policy Guidelines’ [5] and other WA agencies thought to have knowledge of, or experience with, victims of elder abuse. This group of agencies included public and private hospitals, residential aged care facilities, government departments, adult day centres and home and community care providers, which were identified using webbased searches and the White Pages directory. The literature [5– 8] identifies a number of types of elder abuse, with some variation in their definitions. In the WA context, Advocare Inc. [9] and Barrett [1] have similar definitions, which were broadly adopted for this study.
Introduction The phenomenon of interpersonal violence has more recently been considered within age-specific categories. The abuse of older people was first described in journals as early as 1975 [1–2]. In the USA and some jurisdictions in Australia, it has been viewed as a sociopolitical concern, resulting in legislative action. Elder abuse has more recently been recognised in Australia as a significant social issue [3]. The growing worldwide focus on abuse of older people relates to the wider focus on human rights, within the context of population ageing. While mistreatment of older people has undoubtedly occurred over the course of history, social recognition of elder abuse and neglect, and health and public concerns about the abuse of older people, have been more recent developments.
Six types of elder abuse: physical, social, psychological, sexual, material/financial and neglect (excluding self neglect) were included in this study, and defined as follows. Physical abuse: infliction of physical pain, injury or force. Social abuse: restriction of social freedom and isolation from family and /or friends. Psychological abuse: behaviour which causes mental or emotional anguish or fear. Sexual abuse: sexually abusive and exploitive behaviours involving threats, force, or the inability of the person to give consent. Material/financial abuse: the illegal or improper exploitation and/or use of funds or other resources. Neglect: failure to provide, or allow others to provide, a senior with the basic necessities of life (does not include self neglect). Elder abuse in general was defined as:
In preparation for the development of an Elder Abuse Prevention Program, the Western Australia (WA) Office for Seniors Interests and Volunteering commissioned the Freemasons Centre for Research into Aged Care Services, Curtin University of Technology, to undertake a survey to determine: Correspondence to: Professor Duncan Boldy, Curtin University of Technology. Email:
[email protected] Australasian Journal on Ageing, Vol 24 No 1 March 2005, Research 3–8
The neglect or harmful physical, social, psychological, sexual, or material effects caused by the behaviour of a person within whom a senior has an informal relationship implying trust. This definition is similar to that used in a UK Report [10], which has subsequently been adopted by the International Network for the Prevention of Elder Abuse. 3
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Furthermore, it was indicated in the questionnaire that the definition used ‘implies that business relationships (e.g. bank managers) and relationships between service providers and clients (e.g. Home and Community Care [HACC] carer) should be excluded’. This does not imply that such forms of abuse do not take place, nor that they are not important, but that they are not considered elder abuse in the usually accepted definition of this term. Whilst most studies of elder abuse have used 65 years and over as their age definition, in order to be consistent with the definition of ‘seniors’ used by the WA Office for Seniors Interests and Volunteering, the study adopted 60 years and over as its age group of concern. General practitioners (GPs) were considered to be an important group for inclusion in the study. However, advice from relevant industry representatives suggested that direct mail to a broad sample of GPs would probably elicit a very low response. Consequently, questionnaires were sent to a selection of 129 GPs (out of the total of 1254 full-time equivalent GPs in WA) that were known to have an interest in aged care, from two metropolitan and two rural Divisions of General Practice. Responses from this group were considered to be indicative of likely cases of elder abuse presenting to GPs in general in WA. To estimate current prevalence, participants were asked if they had encountered any known or suspected cases (not events) of elder abuse during the previous 6 months. Although the time scale of 6 months is relatively short compared to previous studies, this was chosen to enhance reliability of recall and response rates. Previous studies, including Barrett [1], have typically restricted themselves to identifying ‘known’ cases only. However, given the sensitive and presumed ‘tip of the iceberg’ nature of elder abuse, it was decided to include the category ‘suspected’, so as to provide possibly a more realistic estimate of extent. The definition adopted for ‘known’ was: there is evidence to suggest that abuse occurred, while ‘suspected’ was defined as: in your judgement you have reason to believe that abuse may have occurred.
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Results Response rates and double counting Overall, 340 of 1146 questionnaires were returned, representing a response rate of just under 30%. Response rates by type of organisation varied from 18% for government departments to 68% for adult day centres (see Table 1). In the absence of further information about all organisations (e.g. ‘size’, however measured), respondents were assumed to be representative of their agency type and the results were scaled up (‘weighted’ by type) to provide an overall estimate of the number of cases for WA as a whole. Prevalence rates were calculated by using the weighted number of estimated cases, divided by the relevant residential (i.e. excluding those in institutions) age /sex WA population as at June 2001 [11]. To allow for potential double counting of cases in the estimates of prevalence, the number of reported cases was discounted by the number of cases indicated as having been referred from another agency, prior to the scaling up procedure. This allowance amounts to an overall reduction of approximately 10%. This discount factor has not been applied to the other results presented, as a detailed breakdown of referrals by type was not requested, as it was considered likely to have adversely affected response rates. Prevalence, age/sex group and types of abuse Of the 340 organisations that responded, 83 (24%) indicated that they had encountered known or suspected cases of elder abuse during the previous 6 months. The total number of elder abuse cases encountered by these organisations amounted to 435 (182 known and 253 suspected). When weighted as indicated above, this equated to 1815 total cases in WA as a whole in the specified 6-month period. (It is important to note that only 10% of those organisations providing data about elder abuse had based their information on written records, an obvious potential limitation related to the ‘accuracy’ of data provided). Table 2 illustrates the distribution of known and suspected cases of elder abuse according to age and sex. Women (n = 1355) comprised 75% of known and suspected cases, the latter being most common in those males and females aged 75 years
Table 1: Response rates of organisations surveyed by type Type of organisation Direct mail-out Public/ private hospitals, ACATs Residential aged care facilities Government departments Adult day centres HACC, other community care Other Customised approach General practitioners (GPs) (sample) Total
Surveyed*
Responded
Response rate (%)
101 271 132 22 231 260
37 116 24 15 55 66
36.6 42.8 18.2 68.2 23.8 25.4
129 1146
27 340
20.9 29.7
*For all types, except GPs, this represents the known total. The total number of full-time equivalent GPs as at 30 June 2001 was 1254. ACAT, Aged Care Assessment Teams, HACC, Home and Community Care.
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Table 2: Percentage of elder abuse cases by age group and sex Age group (years)
Females
Males
Known (n = 694) Suspected (n = 661) Overall (n = 1355) 60– 64 65 –74 75+ Prevalence
22 53 25 0.46
19 21 60 0.44
21 37 42 0.90
Prevalence
Known (n = 212) Suspected (n = 248) Overall (n = 460) 22 39 39 0.16
24 20 56 0.19
23 29 48 0.35
0.45 0.51 0.79 0.58
All results are expressed as percentages.
or above. The higher proportion of women compared with men is consistent with most other studies that have made this distinction [e.g. 12 – 14]. The overall prevalence rate for WA was estimated at 0.90% for females and 0.35% for males (0.58% overall). Rates increased with age, being 50% or so higher in the 75 or over age group (0.79) compared to the 65 –74 years age group (0.51). When asked to estimate the actual prevalence of elder abuse, more respondents selected the ‘less than 5%’ category (44%) than any other. However, more than 20% believed that as many as 15% or more of older (60+) persons had been victims of elder abuse. When asked why they thought elder abuse might be underreported, respondents stated that for victims this mainly related to loyalty to the family and fear of the possible consequences. For health professionals this was considered to be because of an unwillingness to become involved, due to the socially unacceptable nature of elder abuse and lack of anonymity for those reporting cases. Two important risk factors identified by survey respondents included the dependency of the victims on their abusers and an inability to make decisions and voice needs, as a result of dementia, poor self image and / or feelings of burden. In our study, decision-making disability was reported in 689 (76%) of known cases and in 389 (43%) of suspected cases of abuse, whilst the figures for those having a significant physical disability were 389 (43%) for known cases and 72 (8%) for suspected cases. Several respondents mentioned intergeneration conflict as an underlying risk factor, other reasons cited included lack of more suitable accommodation, ‘family culture’, ‘an obligation to care with no understanding of dementia or services’, greed and financial difficulty. In the majority of known cases of abuse, the older person experienced at least two different types. Of these, 736 (81%) of cases were reported as financial/material, 499 (55%) psychological, 276 (30%) physical, 229 (25%) neglect, 153 (17%) social and 32 (4%) as sexual abuse. Perhaps not surprisingly, respondents were not as willing to speculate on the type of abuse experienced in suspected cases and the proportion of cases in each of the categories, whilst ranked broadly similarly, was substantially lower; 188 (21%) financial / material, 133 (15%) psychological, 76 (8%) physical, 62 (7%) neglect, 89 (10%) social and 24 (3%) sexual. Australasian Journal on Ageing, Vol 24 No 1 March 2005, Research 3–8
Table 3: Type of direct service offered Service Counselling Provide information on elder abuse Advocacy Mediation Other
No. agencies (%) 244 (68) 176 (49) 175 (49) 121 (34) 46 (13)
Immediate family members were the most commonly reported perpetrators of abuse, including daughters (22%), sons (21%), spouse or de facto (18%), other relatives (17%) and daughter/ son in-law (5%); n = 1815 known or suspected cases. Resources, protocols and interventions On identifying a known or suspected case of elder abuse, most organisations (297, 57%) offered some kind of direct assistance, as well as referring the victim elsewhere. Only 46 (9%) organisations offered solely a direct service. The type of direct service provided is summarised in Table 3. The most common service provided was counselling (244, 68% of those who provided a direct service) and on average two service types were provided to each client. By far, the most frequently mentioned agency to which referral was made was an Aged Care Assessment Team (424, 85% of cases where referral occurred). However, multiple referral was common, other frequently mentioned agencies including medical doctor (220, 44%), counselling service (200, 40%), police (160, 32%), psychologist (115, 23%, the Advocare Abuse Prevention Program (110, 22%) and the Office of the Public Advocate (105, 21%). Fewer than a quarter of respondents used existing protocols related to elder abuse; those that did mostly used protocols or guidelines they themselves had developed. To assist with the development of appropriate strategies for identifying and managing elder abuse, the survey investigated the perceived importance of specific primary prevention strategies and interventions. There was a high level of support for most of the primary prevention options listed in Table 4, with ‘education of professionals in recognising elder abuse’ being rated the most important and ‘helpline’ the least. Specific interventions rated as ‘very important’ by 75% or more of respondents were respite care, advocacy and counselling services. 5
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Table 4: Perceived importance of primary preventions Primary prevention
Level of importance (%) Very
Some
Not
Education of professionals in recognising elder abuse Education of older adults to assert and protect their rights Education of general public in recognising elder abuse Encouraging the strengthening of older persons’ social networks Respite care Public campaigns aimed at improving community perceptions of, and attitudes to, ageing and older persons Helpline
527 520 527 518 520 520
79 74 73 70 70 63
21 25 26 29 28 27
0 1 1 1 2 10
512
50
36
14
Elder abuse in Aboriginal communities Cases reported by four agencies that dealt exclusively with indigenous people accounted for 33 (18%) of known and 27 (11%) of suspected cases of elder abuse. These figures translate into a markedly higher prevalence of abuse in this group, as Aboriginal people aged 60 years or older represent only approximately 1% of the WA population.
and the 43% of such cases estimated to have a significant physical disability. Kurrle et al. [15] cited psychopathology in the abuser (30% of cases) and dependency of the victim (25% of cases) as the two major contributing factors, whilst Cupitt [17] reported that roughly half of all victims had one chronic health problem and one-third had three or more health problems such as dementia, depression, immobility, stroke or arthritis.
Cultural sensitivity related to issues of elder abuse and the ‘Aboriginal way’ of sharing money and resources were considered to be important barriers to reporting abuse. One respondent believed the elder abuse, as defined in the survey, was so entrenched in the Aboriginal community that desensitisation had occurred. The shame of acknowledging abuse was the other factor cited as a major barrier to identifying and resolving the problem.
One might expect physical abuse to be the most frequently identified type, because of its likely visibility. However, material/ financial abuse and psychological abuse were more frequently reported in this study. One could expect psychological abuse to be present in any situation of abuse. The extent of multiple abuse identified in this study, also reported by Kurrle et al. [15], is a further example of the seriousness of the problem. Identifying and implementing effective actions will not be easy, given the typical ‘dependency’ of those being abused and the frequency of abusers being close family members.
Discussion Prevalence and types of abuse This study differs from others using an agency-based approach in that it has surveyed a wide range of agencies potentially having contact with cases of elder abuse. Previous agency-based studies identified were conducted within single key organisations, including Aged Care Assessment Teams (ACATs) [4,15], a geriatric and rehabilitation service [16], and a community nursing and home care service [17]. Their estimates of prevalence relate to the proportion of referred clients, not to the proportion of the older population living in the geographical area served by the agency. These factors almost certainly account for the higher population prevalence rates obtained in the other agency-based studies, which have typically produced estimates of the order of 5%. Whilst elder abuse remains largely hidden, unacceptable and stigmatising, it is unlikely that there will be any increase in the extent of reporting and hence the extent to which a wider range of organisations become aware of its existence. The marked higher rate of elder abuse reported amongst females and those in the oldest age group, as also found by Pavlik et al. [14], is of particular concern, especially given the dramatic ageing of the population and the increased longevity of females compared to males. The vulnerability of those older people who are abused is further illustrated by the 76% of known cases estimated to have a decision-making disability 6
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A wide range of primary preventions were suggested, with specific interventions rated as particularly important being respite care, advocacy and counselling services. Whilst counselling and advocacy are amongst the most frequent direct services offered, respite care was rarely mentioned. Perhaps this indicates a significant gap in service provision for older people who have suffered abuse. In a study of community nurses in New South Wales, 75% of staff identified respite care as the single most common service deficit for family members [17]. ACATs appear to be particularly favoured as a referral agency, indicating their perceived importance and/or knowledge in this area. Protocols aim to assist families and organisations to better understand the issues, to recognise when older people are at risk and to indicate how they might respond when necessary. However, only a minority of organisations that responded to this survey used existing protocols. Study limitations Measuring the ‘true’ prevalence of elder abuse is fraught with difficulty, as has been indicated. Particular limitations of this study relate to: the scaling up (or weighting) process, based on an overall response rate of 30%; the non-random nature of the selection of GPs (which proved unavoidable); and the potential unreliability of reported data, when only 10% of respondents based this on written records. Australasian Journal on Ageing, Vol 24 No 1 March 2005, Research 3– 8
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Conclusions and broad recommendations Whilst this study has identified an estimated prevalence of elder abuse amongst Western Australians aged 60 years and above of less than 1%, studies based on population surveys using interviews have produced prevalence estimates of 5% and above. Furthermore, a substantial minority (22%) of study respondents believed that the figure may even be as high as 15% or more. As discussed, current taboos associated with elder abuse are likely to result in considerable under-reporting remaining the norm for the foreseeable future. In the context of WA, and potentially for Australia as a whole, it is recommended that because of the likely continued uncertainty as to the extent of elder abuse, no further specific efforts /funds are devoted to attempts to produce a more precise estimate of its ‘true’ prevalence.
Acknowledgements We wish to thank the following: the WA Office for Seniors Interests and Volunteering for commissioning the research; Tom Barrett and Beth Kingsley for their helpful advice; Mathew Webb for his contribution; and all of the organisations that found the time to complete and return the questionnaire.
Key Points • Whilst the actual extent of elder abuse is difficult, if not impossible, to ascertain, the prevalence estimates found in this study are of the same order as those obtained in studies using similar approaches.
Education was rated as a particularly important prevention strategy; this included education of both professionals and the general public in recognising elder abuse, and education of older people to assert and protect their rights. Interventions rated as particularly important were respite care (also considered an important contributor to primary prevention), advocacy and counselling services. It is recommended that any existing relevant education programs (targeted at professionals, the general public and / or older people themselves) are appraised as to their adequacy and cost-effectiveness, and new programs developed as needed and evaluated.
• Future efforts and funds need to be targeted at activities aimed at gaining an increased understanding of why elder abuse occurs and what can be done about it. • The current adequacy and availability of desirable interventions needs to be assessed, paying particular attention to respite care, advocacy and counselling services.
References 1 2 3 4
The present study revealed that only 10% of those organisations that provided data about elder abuse had based their information on written records. This lack of recording may in part be associated with the need for further promotion of the development and use of targeted elder abuse protocols by organisations coming into contact with older people likely to be at risk. It is recommended that organisations coming into contact with older people be encouraged to agree on a standard elder abuse protocol, with commonly agreed definitions of the different kinds of abuse and to record details on the elder abuse cases reported.
5 6 7 8 9 10 11
Given the dramatic population projections of an increasingly ageing population in Australia, as elsewhere, and the fact that Australasian Journal on Ageing, Vol 24 No 1 March 2005, Research 3–8
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the probability of elder abuse appears to increase with age, it is vital for humanitarian, equity and economic considerations, that a greater understanding of the causes of the phenomenon of elder abuse is obtained. Also, and most importantly, the necessary political will and resources need to be devoted towards minimising the occurrence of elder abuse and its resulting consequences.
Rather, it is recommended that future efforts / funds are targeted at activities aimed at gaining an increased understanding of why elder abuse occurs and, particularly, what are the most cost-effective primary preventions and interventions, bearing in mind the extent of multiple abuse identified. This would need to include specific attention to people from culturally and linguistically different backgrounds (including indigenous older people).
In addition, it is recommended that the current adequacy of the available range of desirable interventions is appraised, with particular attention being paid to the provision of respite care, advocacy and counselling services, for older people either considered at risk of abuse or having experienced abuse.
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