Abuse and Caregiving
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According to the World Health Organization (2018), abuse of an older person is 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 person. This type of violence constitutes a violation of human rights and includes physical, sexual, psychological, and emotional abuse; financial abuse; abandonment and serious loss of dignity and respect. It can also be the result of intentional or unintentional neglect.
The mistreatment of older adults is one of the more egregious issues confronting society today. According to research completed between 2002 and 2015, the global prevalence of domestic elder mistreatment is 15.7%, or about one in six older adults. The rate approximates 141 million global victims of mistreatment annually (Yon et al. 2017). Yearly estimates for each of the mistreatment types are 11.6% for psychological abuse, 6.8% for financial abuse, 4.2%, for neglect, 2.6% for physical abuse, and 0.9% for sexual abuse. When geographical variations in prevalence estimates are calculated, the rates for Asia are 20.2%, Europe 5.4%, and the Americas at 11.7% (Yon et al. 2017). Ultimately, nearly all international, population-based research has identified elder mistreatment as a family affair perpetrated by informal family caregivers except in instances of sexual abuse which is usually perpetrated by an outside party like a friend or neighbor (McDonald 2018). Some evidence suggests that perpetrators of physical and psychological abuse in Asian countries are children and children-in-laws, while in the United States, Israel, Europe, and Canada, the most likely perpetrator is a spouse/partner.
When elder abuse was recognized as late as the 1960s, it was immediately attributed to the stress of family caregiving. The “situational” or “stress” model which lingers today hypothesizes that as care demands exceed informal caregiving capacity, the likelihood of elder abuse increases (Hudson 1986). The assumption is so entrenched, it has been difficult to give up, even when there is no or little supportive research. Essentially, research has demonstrated that family caregiver stress is not a primary cause of elder mistreatment because many caregivers do cope with stress without resorting to harmful behavior (Brandl and Raymond 2012). Nonetheless, the family caregiving context may increase potential risk for elder abuse by informal caregivers for many reasons, not the least of which is the rapid increase of the oldest old, changing family structures and the advance of dementias in the population in developed countries.
Key Research Findings
Few studies have considered the prevalence of elder mistreatment in representative populations of family caregivers of older people. The majority of studies have opted to include variations on friends, neighbors, paid professionals, homecare workers, and strangers along with family caregivers in their samples. The studies suggest that the prevalence ranges anywhere from 3.2% to 27.5% for those older persons with normal cognition compared to 27.9–62.3% for those with cognitive impairments (Kim et al. 2018). A national, representative study, solely of family caregivers in Ireland, found that one in six or 17% engaged in harmful behavior towards their care recipients, psychological abuse making up 16.6% of the aggression and 2.7% representing physical mistreatment (Lafferty et al. 2016). Moreover, 36.8% of caregivers reported that they engaged in “potentially harmful behavior” meaning behavior that could hurt the older person but may not warrant formal intervention.
The risk factor research on elder mistreatment is limited, inconsistent, sometimes in conflict and includes perpetrators who are not family caregivers. To date, the characteristics of perpetrators that have received strong, global empirical support are the existence of mental health issues, problems with substance abuse, and dependency on the care recipient for such factors as housing and income. The attributes of the older person that have received extensive research backing are functional dependence/disability, poor physical and mental health, cognitive impairment, and a low socioeconomic status (Pillemer et al. 2016).
Because rates of abuse are higher in older persons with dementia than in their cognitively intact counterparts, there has been a growing need to differentiate cognitive status in rate estimates (Yan and Fang 2018). Research based on a national probability sample in Korea studied 467 Korean pairs of community-dwelling people with dementia and their primary family caregivers. Results show that more than a half of the caregivers reported committing psychological abuse and about one out of seven caregivers admitted to physical abuse within the past 3 months (Kim et al. 2018). Risk factors for physical abuse included a non-Alzheimer dementia diagnosis and moderate to severe behavioral and psychological problems related to the dementia, while caregiver factors were associated with low income, inadequate knowledge about dementia, and severe perceived care burden. The risk of psychological abuse was related to severe dementia suffered by the older person, their low income, longer duration of care, and for caregivers, severe care burden. Less rigorous studies have identified additional risk factors such as aggressive behavior from the care recipient, a difficult previous relationship, and the caregiver’s anxiety level (Orfila et al. 2018). Earlier research has shown that caregivers with a lifetime history of abuse from the care recipient were over twice as likely to act abusively towards the care recipient.
Interventions for caregivers were among the first models used to prevent or contain elder mistreatment. These interventions, then and now, rely on services such as personal care, shopping, housekeeping and meal preparation, respite care, education, support groups online, in person and individually and day and night hospitals. Often the services are delivered by multidisciplinary teams that have been evaluated to be effective. There is suggestive evidence that these interventions, when directed specifically to abusive caregivers, may help prevent revictimization (Cooper et al. 2016), and there is some indication that the potential for the onset of abuse may be reduced by caregiver support interventions (Mariam et al. 2015). Nevertheless, the research on interventions is slim when it comes to evidence and, what does exist, seriously suffers from methodological flaws.
- Brandl B, Raymond JA (2012) Policy implications of recognizing that caregiver stress is not the primary cause of elder abuse. Generations 36(3):32–39Google Scholar
- Hudson MF (1986) Elder neglect and abuse: current research. In: Pillemer KA, Wolf RS (eds) Elder abuse: conflict in the family. Auburn House, DoverGoogle Scholar
- World Health Organization (2018) Fact sheet/elder abuse. June 8th. https://www.who.int/news-room/fact-sheets/detail/elder-abuse. Retrieved Jan 2018
- Yon Y, Mikton CR, Gassoumis ZD, Wilber KH (2017) Elder abuse prevalence in community settings: a systematic review and meta-analysis. Lancet Glob Health 1:365–356Google Scholar