Violence Against the Elderly -Analysis of Further Research Needs Based on a Systematic Review of Research
VARSTVOSLOVJE Journal of Criminal Justice and Security year 223 no. 3
pp. 303-335
Teja Prime, Branko Lobnikar, Kaja Prislan
Purpose of the Paper:
The purpose of this paper is to investigate the current state of research on the topic of elder abuse both in the institutional and domestic environment and to present the key findings of existing studies. The paper also aims to shed light on areas requiring additional research and present the directions for further research.
Methods:
A systematic literature review was conducted using the PRISMA method in the Web of Science and Scopus databases. The review included 29 papers published between 2010 and 2021.
Findings:
Elder abuse is an under-researched topic. The lack of research is particularly apparent in the incidence and nature of the problem in the home environment. Previous studies focus on the various forms of abuse, its perpetrators and risk factors. Rates of psychological abuse, neglect and physical abuse are high in nursing homes and among older visitors to ambulatory care facilities and emergency departments, while self-neglect, neglect and psychological abuse are prevalent in the home environment. Women between the ages of 70 and 75, who are socially isolated and require daily care, are more exposed to abuse. The perpetrators of the abuse are most often family members.
Limitations/Applicability of the Research:
The 'paper's findings provide insight into research on elder abuse and can serve as a basis for planning research into this phenomenon. The paper highlights research gaps and introduces opportunities for improvements in the systemic approaches when addressing the issue.
Originality/Relevance of the Paper:
The paper presents the systematic and up to date analysis of past studies on elder abuse. The results are intended for professionals and researchers working in the field.
Key words: violence, abuse, neglect, elderly, systematic literature review. UDC: 343.988-053.9
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Nasilje nad starejšimi - analiza prihodnjih raziskovalnih potreb na podlagi sistematičnega pregleda dosedanjih raziskav
Teja Primc, Branko Lobnikar, Kaja Prislan
Namen prispevka:
Namen prispevka je ugotoviti stanje raziskovalne dejavnosti s področja nasilja nad starejšimi v institucionalnem in domačem okolju ter predstaviti ključne ugotovitve obstoječih študij. Prav tako je cilj osvetliti področja, ki zahtevajo dodatno raziskovalno pozornost in predstaviti izhodišča za nadaljnje raziskave.
Metode:
Izveden je bil sistematični pregled literature opravljen po metodi PRISMA v bazah podatkov Web of Science in Scopus. V pregled je bilo vključenih 29 prispevkov, objavljenih v obdobju med 2010 in 2021.
Ugotovitve:
Nasilje nad starejšimi je premalo raziskano področje, še posebej primanjkuje raziskav o pojavnosti in naravi problematike v domačem okolju. Obstoječe študije se vsebinsko osredotočajo na posamezne oblike nasilja, povzročitelje in dejavnike tveganja. V domovih za starejše in med starejšimi obiskovalci ambulant ter urgentnih oddelkov je visoka pojavnost psihičnega nasilja, zanemarjanja in fizičnega nasilja, medtem ko v domačem okolju prevladuje samozanemarjanje, zanemarjanje in psihično nasilje. Nasilju so pogosteje izpostavljene ženske, stare med 70 in 75 let, ki so socialno izolirane in potrebujejo vsakodnevno oskrbo. Povzročitelji nasilja so najpogosteje družinski člani.
Omej'itve/uporabnost raziskave:
Ugotovitve prispevka dajejo vpogled v raziskovalno dejavnost na področju nasilja nad starejšimi ter lahko služijo kot osnova za načrtovanje raziskovanja tovrstnega pojava v Sloveniji in drugod. V prispevku so izpostavljene raziskovalne vrzeli in predstavljena izhodišča za izboljšave sistemske obravnave problematike.
Izvirnost/pomembnost prispevka:
Gre za enega redkih prispevkov, ki sistematično analizira pretekle študije nasilja nad starejšimi. Rezultati so uporabni za načrtovanje prihodnjih raziskav na tem področju, uporabni pa so tudi strokovnjakom, ki se ukvarjajo z zagotavljanjem zdravstvenih in socialnih storitev starejšim.
Ključne besede: nasilje, zloraba, zanemarjanje, starostniki, sistematični pregled literature
UDK: 343.988-053.9
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1 INTRODUCTION
Elder abuse is recognised internationally as a widespread, complex and growing public health and human rights issue, affecting the well-being of the elderly and causing a myriad of health problems or even the death of the elderly (Botngard et al., 2020; Fang & Yan, 2021; Luzny & Jurickova, 2012; Neuberg et al., 2019). With age come many physiological and psychological changes, a decrease in physical and cognitive abilities, and a shrinking social network, all of which are often accompanied by several health problems (§en & Merci, 2019). As a result, the elderly are one of the most vulnerable demographic groups, as they are often marginalised, isolated and exposed to various types of abuse stemming from negative stereotypes depicting them as helpless and useless members of society (Primc & Lobnikar, 2019). For example, World Health Organization (WHO, 2011) data from 2011 showed that at least half of the elderly population in Europe have experienced some form of abuse. A Slovenian study from 2015 (Primc & Lobnikar, 2019) conducted on a sample of 220 elderly individuals showed that 21% of the respondents experienced one form of abuse. With the rapidly growing elderly population worldwide, this issue will only continue to escalate, yet it is still a widely neglected issue on the systemic level.
This multidimensional problem was first documented in the late 1970s and early 1980s, and the first definitions of this phenomenon were derived from the then existing frameworks developed to define the neglect and mistreatment of children (Alexa et al., 2019). Based on studies among the elderly and health professionals on their perceptions of what abuse means to them, the World Health Organization (WHO, 2002) has formed a universal definition of this phenomenon and defined it as 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. Definitions of this phenomenon, as well as the methods employed for researching it varies according to different legal orders and from country to country (Luzny & Jurickova, 2012). In general, the authors note that elder maltreatment can take various forms of abuse, such as psychological or emotional abuse, physical abuse, economic or financial abuse, sexual abuse, but can also be the result of intentional or unintentional neglect (Alexa et al., 2019; Ben Nathan et al., 2010; Botngard et al., 2020; Luzny & Jurickova, 2012). It can occur in different domestic, private, and institutional settings and perpetrate different individuals, such as caregivers, relatives, spouses, or family members (WHO, 2011). Neuberg et al. (2019) define elder abuse and neglect as refusing or failing to fulfil a caregiver's obligation to meet the needs of elderly individuals' needs to punish or hurt them. A particular form of elder abuse is self-neglect, which is characterised as the behaviour of an elderly person that threatens his/her health or safety. It often manifests itself in an older person as a refusal or failure to provide for their own needs (e.g., water, food, clothing, shelter, personal hygiene, medication) (Dong, 2014).
Research on the prevalence and nature of elder abuse is scarce in Slovenia and around the world, as the topic has so far been studied only partially (e.g. in terms of forms or prevalence of victimisation and risk factors, while other important aspects that should be thoroughly understood in order to plan effective preventive measures remain unexplored). The challenge lies in the lack of consensus across the
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scientific and professional community regarding the definition of elder abuse and the research methodologies employed. Although researchers (Fang & Yan, 2021) are aware that the reliability and validity of measurement or research instruments are crucial to ensure the significance, applicability, and relevance of research, very few studies use instruments with established psychometric properties, which results in significant inconsistencies in approaches and divergences between the results of studies examining the same problem. Other additional challenges may hamper our understanding of elder abuse and determining its prevalence. The findings of various authors show that the elderly find it very difficult to speak up about their experiences of abuse perpetrated by their relatives or nursing home employees due to feelings of helplessness, shame and fear that disclosing the abuse might further aggravate their situation. The awareness of this problem also impacts the incidence of elder abuse, the level of knowledge and the willingness of healthcare professionals to take proper action (Luzny & Jurickova, 2012), as well as the fact that the problem is still a taboo. Furthermore, any cases of abuse remain unreported (Lacher et al., 2016). Press reports, social work centres records, and various small-scale studies suggest that this phenomenon is much more common than official statistical data would suggest. In Slovenia, the main issue lies in the fact that data on the prevalence and nature of elder abuse lack transparency and come from different sources, as individual institutions and bodies do not manage such data in a coordinated manner. Only partial data are available on crimes involving the elderly (e.g. property crime, offences against life and limb, economic crime).
Because the elderly represents as much as 20% of the European and Slovenian population and some of the studies that have been conducted on this topic show a high prevalence of victimisation, elder abuse has not been given sufficient attention from the scientific and professional community, as well as the public at large. Therefore, continuous research on the incidence of elder abuse and understanding the factors affecting the occurrence of this phenomenon, both in nursing homes and in private settings, is essential for planning the measures to ensure the safety of this vulnerable demographic.
The paper presents a systematic review of scientific papers on the topic of elder abuse published over the last ten years. The purpose of the review is to determine the relevance of studying the phenomenon of elder abuse as a form of abuse that is still underreported and much less researched, compared to other forms of violence (such as domestic violence, violence against children and peer violence). The review was performed using the Web of Science and Scopus databases and the PRISMA method. The findings of existing studies on the incidence of elder abuse in both institutional and domestic settings and the main risk factors for abuse are summarised. In addition, various forms of abuse experienced by the elderly are described. The systematic literature review aims to determine the state of research to understand the current approaches, topics and methods, identify opportunities for improvement of research approaches, and identify any research gaps or areas in need of additional research attention. The aim is also to identify opportunities for improvement in terms of the approaches and measures employed in the profession to address the issue, which can serve
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as a starting point for improving the effectiveness of existing mechanisms and the development of more comprehensive systemic measures and management strategies.
2 METHOD
The systematic literature review on elder abuse in the institutional and domestic environment was conducted across two international bibliographic databases, Web of Science (WoS) and Scopus. The same search string with a combination of the following keywords was used for both databases: ((elderly OR »old people« OR senior OR retired) AND (neglect OR violence OR abuse OR mistreatment) AND (»nursing home« OR »retirement home« OR »home environment« OR »senior citizens home« OR hospital)). The search was conducted on May 19th, 2021, using titles, abstracts and keywords to find the relevant papers. The search for results was limited to scientific and conference papers published over the past decade (from 2010 to 2021 inclusive). Inclusion and exclusion criteria are presented in more detail in Table 1..
Inclusion criteria
Exclusion criteria
Papers published in scientific journals or conference papers
Books, book chapters, early discussions, editorials, reviews.
access,
Papers published between 2010 and 2021
Papers published before 2010.
Papers in English and Slovenian Papers in other languages.
Access to the full text
Unavailability of the full text.
Thematic relevance of the paper
Papers not related to elder abuse in the institutional and domestic setting, e.g.: Papers addressing the health of adolescents and women in hospitals. Papers addressing illicit substance abuse among the elderly.
Papers addressing the incidence and type of age-related diseases or injuries (hepatitis C, hip fracture, urinary incontinence, stroke, pneumonia, HIV).
Papers addressing the incidence of suicides and self-harm in the elderly. Papers addressing firearm-related injuries. Papers related to covid-19.
Table 1: Inclusion and exclusion criteria
The process of collecting and identifying relevant papers is presented through the PRISMA diagram in Figure 1.
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Figure 1: The process of searching and selecting literature
_y_
Records screened
All together (n = 1,426)
. I
Records included for full-text review
All together (n = 68)
Records identified through database searching
WoS (n = 667)7 Scopus (n = 2,284) All together (n = 2,951)
	Records excluded with reasons
	All together (n - 34)
	
_f_
Records included for Systematic review
All together (n = 29)
3 RESULTS
Based on the literature collection process described, a query using the selected search string returned a total of 2,951 potentially relevant papers. Considering the inclusion and exclusion criteria and after excluding any duplicates, 29 papers were included in the final analysis. A description of the papers included in the systematic literature review is presented in Table 2.
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Table 2: Description of papers included in the literature review
Author and title of the paper Method and sample size Research purpose
Key findings
[Adams et al., 2014]
Financial Abuse of Older People by a Family Member: A Difficult Terrain for Service Providers in Australia
Qualitative and
quantitative
research (survey and
interviews)
228 chief executive
officers
214 aged care service providers
To determine whether chief executive officers and aged care service providers are well placed on recognising financial abuse against the elderly by their family members, determine the degree of the abuse, and take appropriate action to tackle the problem.
The majority of the respondents (92.6%) recognised financial abuse as one of the forms of abuse perpetrated against the elderly. In the previous 12 months, 128 respondents witnessed 1-5 cases of financial abuse, 22 respondents witnessed 6-10 cases, and nine respondents witnessed more than 50 cases of financial abuse perpetrated against the elderly by their relatives.
[Alexa et al., 2019]
Elder abuse and associated factors in Eastern Romania
Quantitative and qualitative research (use of EASI and medical evaluation) 386 consecutive hospitalised individuals over 65 years of age
To identify the presence of abuse, the type of abuse and the factors associated with the abuse.
At least 21.5% of the respondents experienced at least one form of abuse. Women were more frequently abused than men. Emotional abuse was the most common type of abuse (60.2%) followed by neglect (53%) and physical abuse (22.91%).
[Altintop & Tatli, 2019]
Physical abuse of the elderly: a 4-year retrospective evaluation in the emergency department
Analysis of secondary data
116 individuals over the age of 65 with signs of physical abuse
To raise emergency departments' awareness of physical abuse against the elderly.
63% of the individuals suffered physical abuse. Head injuries were visible in 8.6% of cases, the same percentage of injuries were limb injuries, 4.3% of injuries were due to a fall, and in 2.6% of cases, lip injuries and stab wounds were visible.
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[Ben Natan & Lowenstein, 2010]
Study of factors that affect abuse of older people in nursing homes
Quantitative research -survey
510 nursing home employees
To study the effects of long-term care facility traits on the maltreatment of older people.
Slightly more than half of the employees admitted to perpetrating at least one form of abuse against the elderly in the previous 12 months. The most common forms of abuse were mental and physical neglect, followed by psychological abuse and physical abuse.
[Ben Natan et al., 2010]
Psycho-social factors affecting ,elders' maltreatment in long-term care facilities
Quantitative research -survey
510 nursing home employees 24 directors of the facilities
To examine and analyse major variables affecting maltreatment of the elderly.
273 (53.5%) respondents admitted to perpetrating at least one form of abuse against the elderly in the past year. Psychological abuse was the most common type of abuse (64.3 %) followed by neglect (63.9 %), psychological abuse (23 %) and physical abuse (12.28 %). Sexual and financial abuse were reported by 0.1% of the respondents.
[Bloemen et al., 2015]
Trends in Reporting of Abuse and Neglect to Long Term Care Ombudsmen: Data from the National Ombudsman Reporting System from 2006 to 2013
Analysis of secondary data
11,749 elder abuse and neglect-related complaints per year
To describe trends in elder abuse and neglect in nursing facilities received by the long elder abuse and neglect reported in nursing facilities received by the long-term care ombudsmen.
Physical abuse was the most frequently reported, representing 28% of total complaints over 8 years. The abuse was most often reported by the elderly themselves (38%), and in 60% of the cases, the complaint was resolved to the resident's satisfaction.
[Bostanci Da§tan et al., 2021]
The effect of elder abuse on psychological resilience in individuals 65 years and older admitted to the emergency department
Quantitative research Using the Hwalek-Sengstock Elder Abuse Screening Test and the Brief Psychological Resilience Scale 214 elderly individuals
To determine the effects of abuse on the psychological state of individuals 65 years and older admitted to the emergency department.
It was determined that 20.6% of the seniors had experienced abuse in the past, and the abuse continued for 1.9%. Most of the perpetrators were the spouse (38.6%) or siblings (29.6%). 86.3% of the elderly experienced physical abuse, 40.9% experienced psychological abuse and 9.1% experienced financial abuse.
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Teja Prime, Branko Lobnikar, Kaja Prislan
[Botngard et al., 2020]	Quantitative research -
survey
Elder abuse in Norwegian 3,693 nursing staff nursing homes: A cross-sectional exploratory study
To estimate how often nursing staff had observed abuse towards the elderly and how often they had perpetrated acts of abuse towards the residents in their care over the past year.
76% of nursing staff observed one or more incidents of elder abuse, and 60.3% reported that they had perpetrated one or more forms of abuse. Psychological abuse and neglect were most commonly reported. Male staff reported more acts of physical abuse, while female staff reported more acts of neglect.
[Buzgova & Ivanova, 2011]
Violation of ethical principles in institutional care for older people
Quantitative and qualitative research -surveys and structured interviews 454 employees 488 elderly individuals from 12 residential homes for older people
To define the extent, nature and causes of abuse perpetrated by employees in senior homes towards the elderly.
More than half of the employees (54%) admitted to perpetrating at least one form of abuse against the elderly in the past year, and 65% of the employees had observed abuse perpetrated by their colleagues. The most common forms of abuse were psychological abuse (46%) - of which 70% were recurring incidents and physical abuse (12%) - of which 50% were recurring incidents. Only 11% of the elderly reported the abuse.
[Castle, 2012]
Resident-to-Resident Abuse in Nursing Homes as Reported by Nurse Aides
Quantitative research -survey
4,451 nurse aides
To determine the incidence of resident-to-resident abuse, including verbal, physical, financial, psychological and sexual abuse in nursing homes.
In the past 3 months, 97% of nurse aides observed cases of verbal abuse among the residents, 94% observed cases of physical abuse (pushing, pinching, pulling), 91% observed aggressive behaviour (bullying), 69% intervened when an elderly individual took another elderly individual's property and 77% of the nurse aides observed incidents in which the elderly exposed their private parts to the other residents.
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[Chao et al., 2020]
Elder mistreatment and psychological distress among U.S. Chinese older adults
Analysis of secondary data
3,157 elderly individuals
To examine the association between different types of elder abuse and the symptoms of anxiety and depression.
The incidence of elder abuse was 15.14% (n = 475). Of these, 308 (9.79%) experienced psychological abuse, 33 (1.04%) experienced physical abuse, 6 (0.19%) experienced sexual abuse, 291 (9.3%) experienced financial abuse and 331 (11.1 5%) were subjected to neglect.
[Dong, 2014]
Self-neglect in an elderly community-dwelling U.S. Chinese population: Findings from the population study of Chinese elderly in Chicago study
Analysis of secondary data
3,159 elderly individuals
To examine the prevalence of self-neglect and its specific forms.
Mild self-neglect was observed in 18.2% of the elderly, and moderate to severe self-neglect was observed in 10.9%. The most prevalent forms of self-neglect were unsanitary conditions (17%), followed by the need for home repair (16.3%), hoarding behaviour (14.9%), poor personal hygiene (11.3%) and inadequate living utilities (4.2%).
[Edirisinghe et al., 2014]
Elder abuse among outpatient department attendees in a tertiary care hospital in Sri Lanka
Qualitative and quantitative research (conducting interviews and using the Hwalek - Sengstock Elder Abuse Screening Test) 530 adults over 60
To determine the incidence of abuse towards individuals above 60 years of age attending the outpatient department.
239 (45%) of the elderly individuals reported experiencing abuse. Physical abuse was experienced by 5.6% of the elderly, 26% reported loneliness, 5% reported being ignored, 4% were neglected, and 2.6% of the elderly were victims of financial abuse by their caregivers. There were no cases of sexual abuse.
[Evans et al., 2016]
Diagnosis of Elder Abuse in U.S. Emergency Departments
Analysis of secondary data
6,723,667 elderly individuals
To analyse two national databases to estimate the proportion of visits to emergency departments by elderly individuals receiving a diagnosis of elder abuse.
Abuse was diagnosed in 3,846 elderly individuals, while neglect (32.9%) and physical abuse (32.2%) were the most common types of abuse.
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[Fang & Yan, 2021]
Abuse of Older Persons With Cognitive and Physical Impairments: Comparing Percentages Across Informants and Operational Definitions
Qualitative and quantitative research -conducting interviews and questionnaires 1,002 adults aged 55 years or above with mild to moderate cognitive and/or physical impairments and their caregivers.
To compare the percentages Elderly people reported neglect in 65% of the cases,
of elder abuse reported by older adults and their family caregivers and clinical team members.
psychological abuse in 51.1%, financial abuse in 40.8% and physical abuse in 1.2% of the cases. A large discrepancy was observed in the percentages of abuse reported by caregivers and the clinical team compared to the percentages reported by the elderly.
[Lachs et al., 2016]
The prevalence of resident-to-resident elder mistreatment in nursing homes
Qualitative research and analysis of secondary data - interviews, observation, analysis of medical records, review of incident reports
2011 residents in 10 nursing home facilities
To determine the incidence of resident-to-resident abuse, including verbal and sexual abuse in nursing homes.
407 of the 2011 elderly individuals experienced at least one form of resident-to-resident abuse. The prevalence of resident-to-resident abuse among all participating nursing homes was 20.2%. Verbal abuse was the most common type of abuse (9.1 %) followed by physical abuse (5.2 %) and sexual abuse (0.6 %), which was the least common.
[Luzny & Jurickova, 2012]
Prevalence of elder abuse and neglect in seniors with psychiatric morbidity - example from central Moravia, Czech Republic
Medical records analysis and focus groups
305 elderly individuals 30 nurses
To determine the prevalence of elder abuse and neglect in seniors with psychiatric morbidity.
The prevalence of elder abuse in seniors with psychiatric morbidity was 23.8%. The most common forms of abuse were self-neglect, financial abuse and neglect by others.
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[Magruder et al., 2019]
Abuse, neglect and exploitation in assisted living: an examination of long-term care ombudsman complaint data
Analysis of secondary data
140,497 elder abuse complaints over a period of 8 years
To determine the incidence of abuse in assisted living and skilled nursing facilities based on complaints received by the Long-Term Care Ombudsman in Texas.
Individuals in assisted living facilities reported experiencing abuse in 324 cases. Psychological abuse was reported (28.4%), as well as financial abuse (23.46%), while the least reported type of abuse was sexual abuse (5.56%). Residents of nursing homes reported abuse in 1,823 cases, of which 34.78% were cases of psychological abuse, 19.09% were cases of physical abuse and 5.32% were cases of sexual abuse.
[Moore, 2017]
Abuse of residents in nursing homes: Results of a staff questionnaire
Quantitative research -survey
156 caregivers - nursing home employees
To determine the extent and causes of abuse in nursing homes for older people.
88.5% (n = 138) of the respondents either witnessed or suspected elder abuse. Psychological abuse was the most common type witnessed (47.6 %) followed by neglect (31.9 %) and physical abuse (20.0 %). There were no reports of sexual abuse. Several forms of abuse were observed more than one time, with 90.8% reporting recurrent abuse and 16.5% reporting a single act, or both.
[Neuberg et al., 2019]
Contrasting vantage points between caregivers and residents on the perception of elder abuse and neglect during long-term care
Quantitative research -
survey
171 caregivers
245 elderly individuals
To compare the incidence of elder abuse from the vantage points of elder individuals and caregivers.
In the elderly individuals' group, 101 women and 39 men reported being subjected to abuse. Neglect and abuse were most commonly detected in the elderly between the ages of 75 and 84. Those visited by relatives once a week reported abuse more frequently. 52 female caregivers and 5 male caregivers reported cases of severe abuse. In private nursing homes, caregivers did not report abuse, while it was reported frequently in extended care units (75.4%) and county-owned nursing homes (24.6%).
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[Nisha et al., 2016]
Study on elder abuse and neglect among patients in a medical college hospital, Bangalore, India
Qualitative research -structured interview 200 elderly individuals
To determine the prevalence of various types of abuse and neglect and associated factors among elderly patients attending the urban and rural geriatric clinics.
The overall prevalence of elder abuse or neglect was 16% (n=32) comprised of: verbal abuse (12.5%); neglect (11%); financial abuse in (8.5%); and physical abuse (1.5%). Many elderly patients have experienced multiple forms of abuse. There was a statistically significant association between elder abuse and total financial dependence, lack of social support, and depression among elderly patients.
[Patel et al., 2018]
Prevalence and predictors of abuse in elderly patients with depression at a tertiary care centre in Saurashtra, India
Quantitative research Use of DSM-5, EASI and AAT
100 elderly individuals
To explore the prevalence and predictors of abuse and its relation to various sociodemographic variables in elderly patients with depression.
The prevalence of abuse was 24%. Among those who had experienced abuse, 50% had experienced psychological abuse, 17% had experienced neglect, 8% had experienced financial abuse, and 4% had experienced physical abuse. About 54% of elderly persons with severe depression had experienced abuse. Daughters-in-law (54%) and sons (42%) were the most common perpetrators of abuse. Illiteracy and depression were risk factors for abuse.
[Schiamberg et al., 2012]
Physical Abuse of Older Adults in Nursing Homes: A Random Sample Survey of Adults With an Elderly Family Member in a Nursing Home
Quantitative research -survey
452 adults with elderly relatives receiving nursing home care, older than 65 years
To determine the prevalence and risk factors of staff physical abuse among elderly individuals receiving nursing home care.
110 elderly people (24.3%) experienced physical abuse by caregivers. The most common forms of abuse were beatings and kicks (27%), inappropriate use of restraints, force-feeding (62%) and sexual abuse (1.1%). The risk factor for abuse was age - with each additional year, the odds of abuse decreased by 49%.
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[§en & Merig, 2019]
Determination of abuse and depression in the elderly
Quantitative research -survey
Using the Geriatric Depression Scale and the Hwalek - Sengstock Elder Abuse Screening Test
310 elderly individuals
To assess the prevalence of abuse and depression in elderly individuals.
The prevalence of abuse and depression was higher among women who were divorced or widowed, had a primary school education, had a low income and had no social security. 39% of the individuals suffered abuse.
[Lacher et al., 2016]
Types of abuse and risk factors associated with elder abuse
Analysis of secondary data
903 dossiers created at an Independent Complaints Authority for Old Age in Zurich
To identify types of elder abuse and to investigate its associated risk factors.
A total of 150 cases reflected at least one form of elder abuse or neglect; 104 cases of abuse and 46 cases of neglect. Psychological abuse was the most reported form of abuse (47 %) followed by financial (35 %) and physical abuse (30 %). Abuse was more often experienced by those living at home.
[Smith et al., 2019]
The epidemiology of sexual assault of older female nursing home residents, in Victoria Australia, between 2000 and 2015
Analysis of secondary data
28 forensic examinations performed for alleged sexual assault
To determine the incidence of sexual assault of older female nursing home residents.
The median age of victims of sexual assault was 83 years. The most common location where the sexual assault occurred was the older female resident's bedroom (28.6%). The perpetrators were identified in 53.6%, all were male. The same percentage of perpetrators (25%) were caregivers and other residents. In 3.6% of the cases, the perpetrator was a medical practitioner.
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[Teaster et al., 2015]
The Sexual Victimisation of Older Women Living in Nursing Homes
Analysis of secondary data
64 elderly women, victims of sexual abuse
Analysis of data related to alleged and confirmed cases of sexual abuse in nursing homes.
Of the 64 cases of sexual abuse identified, in 20 cases it was confirmed that the abuse did occur, and in 44 cases there was insufficient evidence of the abuse. The median age of the victims was 81 years. The alleged perpetrator was identified in 90% of all confirmed cases. The average age of the perpetrators was 57, 94% of the confirmed perpetrators were male and 72% of them were other residents. The caregivers were the perpetrators in only two confirmed cases.
[Yon et al., 2019]	Systematic literature
review
The prevalence of elder abuse 55 studies, of which 9 in institutional settings: A were selected for review systematic review and meta-analysis
A systematic review of the literature on the prevalence of elder abuse in institutional settings in the past 12 months.
The findings suggest that 64.2% of staff admitted to elder abuse in the past year. Residents reported being subjected to psychological abuse (33.4%), followed by physical (14.1%), financial (13.8%), neglect (11.6%), and sexual abuse (1.9%).
[Zhang et al., 2012]
Family Members' Reports of Non-Staff Abuse in Michigan Nursing Homes
Quantitative research -survey
2,004 adults with elderly relatives receiving nursing home care, older than 60 years
To determine the prevalence and risk factors of staff and non-staff elder abuse in nursing homes from family members' perspectives.
36.5% of the respondents reported that a relative in a nursing home had experienced staff abuse in the past year, while 10% had experienced non-staff abuse.
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Of the 29 papers included in the systematic literature review, 13 identified the incidence and forms of abuse and the factors related to elder abuse in nursing homes, of which two specifically addressed sexual abuse of elderly female individuals, and one explored financial abuse of the elderly. Ten papers addressed the incidence of elder abuse towards individuals attending ambulatory care facilities and emergency departments, of which one of the studies focused on the abuse of elderly individuals with cognitive impairments and one on the abuse of elderly individuals with psychiatric illness. In three papers, the authors analysed the complaints submitted by elderly individuals to the Long-Term Care Ombudsman or other services in charge with processing such complaints. In two papers, the authors analysed the incidence of self-neglect and the association of elder abuse with symptoms of anxiety and depression among the elderly based on secondary data collected in the PINE study. In one paper, the authors used the systematic literature review method to study the incidence of elder abuse in nursing homes in the past 12 months. The most commonly employed quantitative research method (11 papers) was conducting surveys or using specific psychometric tests. In nine papers, the authors analysed secondary data, and in five papers, a combination of quantitative and qualitative research (surveys and interviews or focus groups) was used. In one paper, qualitative research was used, in the remaining two papers, the authors used a combination of quantitative research and secondary data analysis and qualitative research and secondary data analysis.
3.1 The findings of studies on elder abuse in nursing homes
Studies of elder abuse in an institutional setting have generally focused on the perception or reporting of abuse by medical and other staff, the elderly, and their family members. Between 54% and 60% of nursing home staff admitted to perpetrating at least one form of elder abuse in the previous 12 months before the survey was conducted, and 65% - 76% of nursing home staff witnessed an incident in the same period where a co-worker perpetrated one or several forms of elder abuse (Ben Natan & Lowenstein, 2010; Ben Natan et al., 2010; Botngard et al., 2020; Buzgova & Ivanova, 2011). In a study aimed at determining how many times nursing home staff had witnessed elder abuse in their previous job, caregivers reported the occurrence or the suspicion of abuse in 88.5%. The authors attribute the higher percentage of reported abuse in this study to the fact that caregivers find it challenging to report having observed or perpetrated abuse, as they are afraid of how their employer, supervisors or other co-workers might react, which is the main reason why they do not speak up. When asked about the incidence of abuse at a previous employment, they were more likely to talk about it (Moore, 2017).
Most cases of abuse by caregivers and medical staff were psychological abuse (23% - 46%), with 21% - 70% of cases involving recurring incidents (Ben Natan & Lowenstein, 2010; Botngard et al., 2020; Buzgova & Ivanova, 2011). The predominant forms of psychological abuse were yelling, arguing with a resident, insults and name-calling. The authors (Botngard et al., 2020) attribute the high
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rate of yelling and arguing to the fact that staff might perceive this as everyday communication within a nursing home setting. Active neglect was reported by staff in 1% - 34%, while 64% of the respondents reported that physical neglect occurred more than 16 times a year (Ben Natan & Lowenstein, 2010; Botngard et al., 2020; Buzgova & Ivanova, 2011). The most frequent reported acts were neglecting oral care (30.5%), ignoring a resident (25.3%), deliberately delaying care (19.5%) and prohibiting a resident from using the alarm (11.7%) (Botngard et al., 2020). The authors (Ben Natan & Lowenstein, 2010; Botngard et al., 2020) attribute the high rate of reporting neglect to the fact that staff are more inclined to report neglect because it constitutes an omission of a particular act instead of intentionally perpetrating abuse. They perceive neglect as systemic failures rather than their failure to meet the basic needs of the residents (e.g., neglecting oral care is attributed to lack of time or adequate equipment, inadequate training in delivering oral care, or 'residents' resistance to care ...).
Caregivers reported physical abuse in 9.6% - 12%, where 2.2% - 50% were recurrent acts (Ben Natan & Lowenstein, 2010; Botngard et al., 2020; Buzgova & Ivanova, 2011). The most frequent acts were pushing, grabbing or pinching a resident and deliberately delaying giving medications. Male staff reported more acts of physical abuse, while female staff reported more acts of neglect. Additionally, higher-educated staff admitted perpetrating more acts of physical and psychological abuse and neglect (Botngard et al., 2020). Staff were the least likely to report financial (0.1% - 1%) and sexual abuse (0.1% - 0.7%) (Ben Natan & Lowenstein, 2010; Botngard et al., 2020; Buzgova & Ivanova, 2011). The authors (Botngard et al., 2020) attribute low rate of reporting sexual abuse to the fact that sexual elder abuse is the most shocking form of abuse, and therefore considered the most hidden and least acknowledged. Ageism and stereotypes about older adults as non-sexual beings might impede nursing staff in recognising and reporting this type of abuse.
Nursing staff who witnessed abuse being perpetrated by their co-workers most often observed psychological abuse (47.6% - 62.4%), with 43.3% reporting they observed this form of abuse on two or more occasions (Ben Natan et al., 2010; Botngard et al., 2020; Moore, 2017). The most frequently observed forms of abuse, in addition to yelling, arguing with the residents, and name-calling, were ignoring a resident, making critical remarks to a resident, verbal abuse, threat of eviction, and threat of catheterisation (Botngard et al., 2020; Moore, 2017). The second most commonly observed abuse form was neglect (9% - 57.8%), where 40.1% were recurrent acts (Ben Natan et al., 2010; Botngard et al., 2020; Buzgova & Ivanova, 2011; Moore, 2017). Other observed forms of neglect included not giving food and drinks, leaving residents in wet clothes or undressed, not washing residents, leaving and forgetting residents on the toilet, unnecessarily sitting in wheelchairs, and placing call buttons out of reach (Moore, 2017). Nursing home staff reported acts of physical abuse committed by their co-workers in 23% - 30% of cases, with 8.7% - 63% being recurrent acts (Botngard et al., 2020; Buzgova & Ivanova, 2011; Moore, 2017). In addition to pushing, pinching, grabbing, and deliberately delaying giving medications (Botngard et al., 2020), physical restraint, forcing residents to get up against their wishes, punches to the hands, face, and legs,
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rushing with feeding, over-medication, and giving unprescribed medication were observed (Moore, 2017). As with reported abuse, the least observed forms of abuse were financial (2.1%) and sexual abuse (1.6%). Prevalence rates of perpetrated abuse were lower than rates of observed abuse, suggesting that staff find it easier to report abuse they observe committed by colleagues rather than admitting their own abusive behaviour (Botngard et al., 2020).
Adams et al. (2014) analysed the detection of financial abuse among aged care service providers and chief executive officers in nursing homes and their difficulties and success in dealing with cases of elder financial abuse. According to the authors, financial abuse is the most common form of elder abuse in Australia. This type of abuse consists of the improper and illegal use of an elderly person's financial resources. This may include, for example, pressuring an elderly into changing a will in favour of specific individuals and preventing the elderly person from spending or accessing their own money, stealing money or extorting money from an elderly person, and abusing one's rights as an elderly person's legal guardian. Survey respondents (228 chief executive officers and 214 aged care service providers) reported in 92% that they recognise financial abuse as one of the forms of elder abuse, but often find it challenging to act against it. More than a quarter (27.8%) of the respondents reported that financial abuse is a common form of reported or alleged elder abuse at their establishment. 70% of the respondents reported having specific measures in place to address this form of abuse. According to respondents, the number of reported cases of elder financial abuse perpetrated by relatives in the previous 12 months prior to the survey was between 620 and 1,300 cases. The authors attribute the number of detected cases to greater awareness of this issue and not to a higher incidence of this form of abuse in general. Respondents reported that the most common problems they encountered included difficulties in detecting abuse, obtaining the elderly person's consent before they could take action, the risk that the abusive relatives would transfer the elderly person to another nursing home, and a lack of resources to deal with the complexities inherent in situations of financial abuse. Elderly people are reluctant to report abuse for fear of causing a rift in the family or because they believe it to be a private matter. Family members often react violently when nursing staff share their suspicion of financial abuse. Some staff members might not want to interfere in the elderly person's life, as they find it difficult to ask the right questions without feeling intrusive and without causing conflicts with the family members (which can ultimately cause more harm to the elderly person). Obtaining the consent of the elderly person to take action against abuse is all the more difficult when the person has dementia. Some respondents acknowledged that they find it challenging to report and take action against abuse in cases in a smaller rural area where they also live. Non-reporting abuse is also the result of a lack of legal protection for those who report abuse.
Nevertheless, many institutions have taken a proactive role in addressing the financial abuse of the elderly. Almost 80% of the respondents said that their institutions have included financial abuse in their organisation's definition of elder abuse. Both the chief executive officers and aged care service providers reported several successfully resolved cases of financial abuse by lodging a complaint with
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the Guardianship Board (n = 23), requiring the Public Advocate to investigate the matter (n = 16), reporting the matter to the police (n = 8), talking to the abused elderly person's relatives (n = 10) or intervening in the case themselves (n = 13). Some institutions deal with this issue through their financial service, which is tasked with identifying cases where there are insufficient funds to pay for care or to pay pharmacy bills. The manager or CEO of the institution is then informed about the suspected financial abuse of an elderly person and decides on what action needs to be taken.
Smith et al. (2019) found that sexual abuse is the least acknowledged, detected, and reported type of assault against nursing home residents. The study identified 28 forensic medical examinations performed for alleged sexual assault of elderly women between 2000 and 2015. The actual number of identified cases can vary significantly due to under-reporting by the elderly female victims and lack of identification by nursing home staff. The median age of the victims was 83 years, and most of them had cognitive impairments. The perpetrators were identified in 53.6%, all were male. The same percentage of perpetrators (25%) were caregivers and residents and in 3.6% of the cases the perpetrator was a physician. An examination cannot proceed if the victim is unwilling or unaware of what they are consenting. Forensic evidence is therefore limited by the inability to conduct a complete examination to.
Teaster et al. (2015) also agree that no type of elder abuse is so underreported as sexual abuse. The study identified 64 cases of sexual abuse, however, upon closer analysis, in 20 cases, it was confirmed that the abuse did occur, and in 44 cases there was insufficient evidence of the abuse. The median age of the victims was 81 years. The alleged perpetrator was identified in 90% of all confirmed cases. The average age of the perpetrators was 57, 94% of the confirmed perpetrators were male and 72% of them were other residents. The caregivers were the perpetrators in only two confirmed cases. Contrary to the findings of a study by Smith et al., (2019), in most cases, the victim was not offered the option of a forensic medical examination an assessment by a nurse to identify any injuries that might be the result of abuse; however, support was offered to all victims (both substantiated and unsubstantiated cases). In most cases, victims reported sexual harassment or inappropriate behaviour such as expressing sexual interest in the victim's body, with three cases involving vaginal rape. None of the substantiated cases of abuse resulted in the perpetrator's arrest. Agencies with authority to investigate alleged sexual abuse in nursing homes require evidence sufficient to warrant confirmation of an allegation. Cases, where there was insufficient evidence of abuse, may include actual cases of sexual abuse for which investigators believed there was insufficient evidence to justify a positive finding. This could happen due to various reasons such as contamination or loss of evidence, witnesses and victims may have been fearful of retaliation and recanted statements, and delays of physical examinations of alleged victims or no examinations may have occurred (Teaster et al., 2015). Analysis of reported cases of elder sexual abuse in an institutional setting could help to improve our understanding of the vulnerabilities, injuries and (physical and emotional) responses that are unique to older victims, and therefore aid in
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the development of age-appropriate prevention and treatment strategies (Smith et al., 2019).
Studies have found that the rates of elderly residents reporting experiencing abuse are very different from the reporting rates by nursing staff. In a study by Buzgova & Ivanova (2011), where more than 50% of nursing home staff admitted to perpetrating at least one form of abuse, the elderly residents reported having experienced abuse in only 11% of the cases, while only 5% observed that their roommate was a victim of abuse by the staff. While 46% of the nursing home staff reported perpetrating psychological abuse, only 10% of the elderly residents reported experiencing it. About 12% of the nursing home staff admitted to perpetrating at least one form of physical abuse, but less than 2% of the elderly residents reported experiencing it. In a study by Neuberg et al. (2019), 72.1% of elderly women and 27.9% of elderly men reported being subjected to abuse. Neglect and abuse were most commonly detected in the elderly between the ages of 75 and 84 (43.6% of the respondents). Residents whom relatives visited once a month or once or several times a week reported having experienced abuse more often (76.5%), indicating that family support plays an essential role in identifying and recognising abuse in an institutional setting. The perception of abuse was more frequent among elderly individuals with a moderate level of mobility and those receiving care in extended care units. Serious mistreatment was observed in 91.2% of female caregivers and 8.8% of male caregivers. Serious mistreatment was most commonly observed by the respondents under 31 years of age. Abuse was more frequently perceived by morning shift nurses, because the number of nurses working the morning shift and seeing each other work is larger, and hence they notice abuse more often.
The prevalence and risk factors of staff physical abuse among elderly individuals receiving nursing home care from the perspective of family members were investigated by Schiamberg et al. (2012). According to a sample of 452 relatives of older people in nursing homes, 24.3% of elderly individuals reported being subjected to abuse by nursing home staff. Of these, 27% were exposed to beatings, kicks and similar forms of physical abuse, 62% experienced inappropriate use of restraints, forced toilet use or force-feeding, and 11% were victims of sexual abuse. A statistically significant risk factor was the elderly person's age. The study showed that with each additional year, the odds of abuse decreased by 49%. The risk of physical abuse was higher in those elderly residents who had one or more limitations in activities of daily living. Needing help with moving around increased the risk of abuse by as much as 89%. In a study by Zhang et al. (2012), 36.5% of the respondents reported that a relative in a nursing home had experienced staff abuse, while 10% had experienced non-staff abuse. Among those who reported experiencing staff abuse, 19% also reported abuse by other residents. The prevalence of elder abuse from relatives' point of view is significantly higher than the findings of studies where abuse was reported by staff and the elderly themselves. According to the authors, most incidents reflect poor provision of care services by caregivers. Hence, training the nursing staff on how to manage potentially frustrating situations in providing care services is
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essential and could prove effective in reducing physical abuse in nursing homes (Schiamberg et al., 2012).
An increasing number of studies report on resident-to-resident elder mistreatment (R-REM) in nursing homes as a subcategory of elder abuse. R-REM can cause physical and psychological injury and death and is defined as hostile and aggressive physical, sexual, or verbal interactions between long-term care residents that in a community setting would likely be construed as unwelcome and have high potential to cause physical or psychological distress in the recipient. (Lachs et al., 2016). In 67% of nursing homes, caregivers reported a high rate of perceived yelling from other residents, and overall, 97% of caregivers witnessed yelling from other residents over the past three months. A high level of physical abuse was perceived by 35% of the caregivers, and overall 94% of the caregivers witnessed physical R-REM during the same period. The physical abuse often consisted of pushing, grabbing, or pinching, while hair pulling and kicking were less common. Caregivers reported the same percentage of perceptions of psychological abuse (aggressive behaviour and threats) in the past three months. 69% of the caregivers reported intervening in cases where an elderly resident took another resident's belongings, while 14% reported intervening in cases where a resident stole money from another resident. 77% of caregivers reported perceptions of sexual abuse when residents exposed their private body parts to other residents (Castle, 2012). In a study by Lachs et al., (2016), 20.2% of all the residents in a nursing home were exposed to at least one form of R-REM over a period of one month. Many of them experienced several forms of abuse; 9.1% were exposed to verbal abuse (yelling, swearing), 5.3% experienced an invasion of privacy, menacing gestures and damage to property, 5.2% experienced physical abuse (beatings, pushing) and 0.6% were subjected to sexual abuse. Most of the incidents occurred in the elderly person's room (40.3%), in the dining room (37.1%) and in everyday activities areas (23.8%). In terms of when the incidents occurred, most of them occurred in the afternoon (40.8%) and in the morning (37.8%), while a lower percentage of them occurred at night (7.4%). The prevalence of incidents was lowest in the summer, and incidents occurred more frequently in facilities for elderly people with dementia. The prevalence of abuse decreased with the age of the elderly person. With each additional year of age, the probability of resident-to-resident mistreatment decreased by 5%, and by 46% for male residents. Elderly people between the ages of 60 and 69 were three times more likely to be exposed to abuse than those over the age of 90 (Zhang, et al., 2012).
The findings of these studies reveal significant differences in the prevalence of abuse in relation to certain risk factors or other influencing factors. According to the type of facility, abuse was not reported by caregivers in private nursing homes, while it was reported frequently in extended care units (75.4%) and county-owned nursing homes (24.6%). This can be attributed to a more open relationship in private nursing homes, greater awareness about abuse among caregivers, and more frequent visits by relatives and friends of the elderly. In county-owned nursing homes, caregivers tend to view the elderly as individuals who can no longer live alone because they urgently need full-time care and who have come to the home to spend the last days of their life. In contrast, a study
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conducted by Ben Natan & Lowenstein (2010) found no association between the type of facility (for-profit or non-profit) and the prevalence of abuse. The risk of neglect and abuse was higher in larger facilities with high staff turnover, and where there is a greater number of elderly people requiring care. The authors state that larger nursing homes have a more significant number of elder residents with more complex needs as well as dementia, which puts much pressure on caregivers and carers. An examination of the impact of staff characteristics (length of service, experience working with the elderly, burnout, knowledge, attitudes towards the elderly and attitudes towards elder abuse), the characteristics of the elderly and the characteristics of the nursing facility on the occurrence of elder abuse showed that emotional burnout and intense feelings of depersonalisation among the staff increase the risk of perpetrating elder abuse. Additionally, a higher risk of perpetrating abuse is also associated with having more experience working with the elderly. Some authors did not find a link between academic knowledge, more years of service, attitudes towards abuse, and the gender and age of the employees (Ben Natan et al., 2010), while Buzgova & Ivanova (2011) found that employees with over five years of service and those with inadequate education were more likely to be the perpetrators of abuse. In relation to the characteristics of the elderly, women, especially those who have dementia, were at greater risk of physical abuse, neglect and other types of abuse (Ben Natan et al., 2010; Buzgova & Ivanova, 2011).
3.2 The findings of studies on elder abuse among individuals attending ambulatory care facilities and emergency departments
Studies examining elder abuse towards individuals attending ambulatory care facilities and emergency departments refer to elderly people who have visited ambulatory care facilities to receive medical assistance. Abuse reported by the elderly or perceived by medical staff was experienced by the elderly in their home environment.
Ambulatory care facilities and emergency departments have been shown to be important sites for identifying various types of abuse, including intimate partner violence, child abuse, and also elder abuse (Evans et al., 2016). The results of these studies cannot be generalised to a specific community or environment, because visitors to ambulatory care facilities come from various places. Furthermore, the sample does not include those who do not have access to medical care, who have dementia or other forms of cognitive impairment (Edirisinghe et al., 2014).
Research conducted on this topic has shown that the overall incidence of abuse of elderly visitors to ambulatory care facilities and emergency departments was between 16% and 45% (Alexa et al., 2019; Altintop & Tatli, 2019; Bostanci Da§tan et al., 2021; Edirisinghe et al., 2014; Evans et al., 2016; Nisha et al., 2016; Patel et al., 2018; §en & Meric, 2019). Physical abuse was the form of abuse most commonly reported by the elderly (4% - 84.4%) (Alexa et al., 2019; Alintop & Tatli, 2019; Bostanci Da§tan et al., 2021; Edirisinghe et al., 2014; Evans et al., 2016; Nisha et al., 2016; Patel et al., 2018). A higher incidence of physical abuse was detected in the younger seniors age group (65-74 years) (Alexa et al., 2019). The types of
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injuries suffered by the elderly were head, limb and lip injuries, as well as stab wounds. The causes of the injuries were mostly punching, hitting with various objects, kicking and strangulation (Altintop & Tatli, 2019). Psychological abuse was reported by between 5% and 60.2% of the elderly (Alexa et al., 2019; Bostanci Da§tan et al., 2021; Edirisinghe et al., 2014; Nisha et al., 2016; Patel et al., 2018). The third most commonly reported form of abuse was neglect (4 % - 53 %), (Alexa et al., 2019; Edirisinghe et al., 2014; Evans et al., 2016; Nisha et al., 2016; Patel et al., 2018). In the majority of cases, family members left the elderly without any food, denied them access to health care, and neglected their oral hygiene (Edirisinghe et al., 2014). A higher incidence of neglect was detected in the elderly aged between 75 and 84 (Alexa et al., 2019). Financial abuse was reported less frequently by the elderly (2.6 % - 9.1 %) (Bostanci Da§tan et al., 2021; Edirisinghe et al., 2014; Nisha et al., 2016; Patel et al., 2018) while sexual abuse was not reported at all (Alexa et al., 2019; Patel et al., 2018). A study by Edirisinghe et al. (2014), which focused on the incidence of elder abuse among outpatient department attendees in a tertiary care hospital in Sri Lanka, showed that abuse is less common in Asia as the extended family acts as a protective factor. Asian societies have a number of socio-cultural and religious practices based on the concept of the extended family. These values include caring for the elderly by the younger generation, which is why it is not uncommon for the elderly in Asian societies to live with their children, nieces and nephews. However, with globalisation and the migration of younger families, these values and practices have changed. The study found that 45% of the elderly experienced at least one form of abuse. Despite the fact that most elderly people live with children and grandchildren, severe loneliness was reported by 26% of the elderly.
Several studies have found that women were more likely to be victims of abuse than men (Alexa et al., 2019; Evans et al., 2016; Nisha et al., 2016; §en & Meric, 2019). In some places, they even represent 73.7% of all victims of abuse (Evans et al., 2016). Higher rates of exposure to abuse were found for: single or widowed women aged between 70 and 74 who had an extended family and needed daily support or care, who lived alone in the city, were economically deprived and without social security, who were under treatment for a specific disease and who had only a primary school education (or lower). The higher prevalence of abuse among those with a lower education level can be attributed to a lack of awareness of the various forms of abuse, the fact that many forms of violent behaviour are considered culturally acceptable and expected, the fear of stigmatisation and the fear that their distress would increase if they decided to speak out on the abuse (Bostanci Da§tan et al., 2021; Edirisinghe et al., 2014; §en & Meric, 2019). According to the type of abuse, verbal and financial abuse and neglect were the most common ones, and elderly women were exposed to physical abuse three times more often than men (Nisha et al., 2016). In contrast, a four-year study by Altintop and Tatli (2019) found that of the 116 individuals with signs of physical abuse identified, 69% were men. According to the studies, the most common perpetrators of abuse were daughters-in-law, children, partners, siblings and others (Alexa et al., 2019; Bostanci Da§tan et al., 2021; Patel et al., 2018).
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An analysis of the findings of the studies above allows us to highlight some other risk factors for abuse. Patel et al. (2018) listed illiteracy and depression as risk factors. The study results also showed that widows and widowers, homemakers, the illiterate and the unemployed were those most exposed to abuse among the elderly suffering from depression. Depression as a risk factor was also identified by §en and Meric (2019), as it was confirmed in 46.2% of the respondents. In addition to depression, Nisha et al. (2016) found a statistically significant association between abuse, complete financial dependence, living conditions, and a weak social network.
Mental illness, as a specific risk factor, was confirmed by Luzny and Jurickova (2012) in their study. The results of focus groups in a psychiatric hospital showed a low level of knowledge and awareness of elder abuse and neglect among the nursing staff. 16.7% of them have never heard about symptoms of elder abuse or neglect, 33.3% had only partial knowledge about it, and 50% of the nursing staff had good knowledge about this issue. The prevalence of elder abuse in seniors with psychiatric morbidity was 23.8%, compared to somatically ill seniors, which was significantly lower (2.9%).
A study by Bostanci Da§tan et al. (2021) was the only one to address how victims react to abuse and what happens after an incident. 75% of the victims did not talk about the abuse after experiencing it, 9.1% reported the abuse to the police, 4.5% received an apology from the perpetrator and the same percentage of the victims ended their relationship with the perpetrator, 2.3% of the victims left their home and the same percentage of the victims responded to the abuse with physical violence.
Fang and Yan (2021) dealt with the perception of elder abuse from three different aspects - the perspective of relatives, the elderly individuals themselves and the clinical team. 1,002 adults aged 55 years or above with mild to moderate cognitive and/or physical impairments and their caregivers participated in the study. The majority of the participating seniors were men (55.6%). More than 90% of them lived with their guardians, who were their adult children (59.4%) or partners (19.5%) and other relatives (21.1%). The study's findings showed a large discrepancy in the percentages of abuse reported by caregivers compared to the percentages reported by the elderly and the observations of the clinical team. Elderly individuals reported neglect in 65% of the cases (not receiving help with washing, getting to the toilet, eating), and their caregivers reported abuse in 50.2% of the cases, while the clinical team noticed signs of such abuse in only 35.4% of the cases. According to the elderly individuals, the second most common form of abuse was psychological abuse (51.1%, which consisted of yelling and name-calling), while the caregivers reported this form in only 42.8% of the cases, and the clinical team in 11.1% of the cases. Financial abuse was reported by 40.8% of the elderly, 34.2% of the caregivers, and the clinical team in only 17.9% of the cases. In most cases, the abuse consisted of the guardian spending the elderly 'person's money for their own needs (a sense of entitlement to money) and preventing the elderly person from spending their money, to ensure a larger inheritance for the guardian. Physical abuse was the rarest form of abuse to be reported. The elderly reported it in 1.2% of the cases and the guardians in 1%. The authors attribute
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the small percentage of guardians reporting abuse to the guardians' reluctance to report abuse for fear of accusations and damaging the family's reputation. The discrepancies can be attributed to the different methods used in the study, indicating the importance of a unified operational definition and method of measuring the incidence of abuse, as well as the need to obtain data from different sources (the victims themselves, their guardians and the medical staff). The lower percentage of perceived abuse by the clinical team raises the question of whether medical staff hold the (wrong) assumption that only intentional behaviour constitutes actual abuse, especially in cases where the abuse is more subtle. Due to the lack of visible signs of abuse, the observation method usually detects less abuse than self-reporting. Nevertheless, the observation method can be helpful for detecting severe cases of elder abuse when the victims are too scared to report the abuse. The results of the study also revealed a general lack of knowledge about elder abuse, both among caregivers and the elderly, as well as the medical staff. All three groups of participants would benefit from additional training, which would enable them to detect and recognise abuse more quickly, as well as take appropriate action.
3.3 The findings of studies on elder abuse in domestic settings
Little is known about elder abuse in private or domestic settings in different communities compared to elder abuse in institutional settings. The Dong study (2014) focused on the incidence of self-neglect among the elderly Chinese population in Chicago. The Chinese community is the largest and fastest-growing Asian-American population subgroup in the United States. Over the past decade, the Chinese community of people over the age of 65 has grown by 55%. Self-neglect in the elderly is the most commonly reported problem at adult social work centres there. Despite the high incidence of this problem, there is very little research done in this area, compared to research on other forms of elder abuse, mainly due to the difficulties in recognising and addressing this problem and the inconsistent definitions of self-neglect. The National Centre on Elder Abuse (NCEA) defines self-neglect as the behaviour of an elderly person that threatens his/her health or safety. It often manifests itself in an older person as a refusal or failure to provide for their own needs (e.g., water, food, clothing, shelter, personal hygiene, medication). Of the 3,159 respondents, mild self-neglect was observed in 18.2% and moderate to severe self-neglect was observed in 10.9%. The most prevalent forms of self-neglect were unsanitary conditions (17%), need for home repair and inaccessibility (16.3%), hoarding magazines (14.9%), poor personal hygiene (11.3%) and inadequate living utilities (4.2%). The prevalence of self-neglect was higher in the elderly with poor quality of life. Cultural and linguistic barriers to accessing health services lead to poor health and an increased risk of self-neglect. Elderly people in the Chinese community affected by poor economic conditions, which make it impossible for them to afford the help of various care units, are even more exposed to living in a dangerous and unhealthy environment. Healthcare professionals should pay more attention to signs of self-neglect in the elderly who report a lower quality of life. They should also be made aware of the
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importance of factors that affect self-neglect that could be integrated into routine history taking in a clinical setting.
Chao et al. (2020) used the same pattern as the author in the previously described study to examine the association between different forms of elder abuse, symptoms of anxiety, and depression among the elderly Chinese population in Chicago. According to the study, 15.14% (n = 475) of elderly people experienced abuse. Of these 11.1% experienced neglect, 9.79 % experienced psychological abuse, 9.3% experienced financial abuse, 1.04% experienced physical abuse, and 0.19% experienced sexual abuse. The reason for the lower percentage of reported sexual abuse, according to the authors, is the silence of the victims, as traditional Chinese culture dictates that rape is shameful and must remain a private matter. Those who experienced any of the listed forms of abuse were more likely to show symptoms of anxiety, as well as more likely to report symptoms of depression. There was no significant association between sexual abuse and depressive symptoms. Depression and its symptoms, however, were significantly associated with age, income, marital status, general health status, quality of life, and changes in health over the past year. It is not clear whether the signs of depression and anxiety are the cause or consequence of the abuse experienced. As the findings of other studies show that the most commonly reported form of abuse is psychological abuse, the authors attribute such discrepancies in the results to different definitions of abuse, methodological approaches and sampling procedures. As many older people are unaware of the forms of assistance available to them, health professionals should make an effort to establish a connection between social work centres and the elderly population.
3.4 The findings of studies on complaints of violations of the rights of the elderly
The Long-Term Care Ombudsman program [The Ombudsman] is the largest and most well-established national program advocating for the health, safety and well-being of the residents of long-term care facilities in the United States. Among its other activities, the law requires the Ombudsman in each country to identify, investigate and resolve complaints made by or on behalf of the elderly residents and to ensure that they have regular and timely access to the Ombudsman's services. In 1996, the National Ombudsman Reporting System [NORS] was developed, which allows for the efficient collection and analysis of information relating to the Ombudsman's activities (Bloemen et al., 2015). Long-term Care Ombudsman staff are advocates for the elderly who empower and assist the elderly with their complaints about the quality of care and violations of residents' rights of nursing homes and other qualified care facilities. Their services are provided for free (Magruder et al., 2019). They are often the first to receive a complaint and respond to it. An Ombudsman may decide to resolve complaints through mediation, acting on behalf of a nursing home resident, or reporting incidents to the police. Ombudsman staff and volunteers also carry out unannounced visits to these facilities, where they check for issues related to the residents' living conditions, listen to the concerns of residents and try to solve
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problems together with or on behalf of the elderly residents (Bloemen et al., 2015; Magruder et al., 2019).
The Ombudsman program in the United States is primarily intended to identify and take action in cases of reported physical abuse perpetrated by employees. Cases of abuse by relatives, friends or others are reported to the centre for social work. Although the findings of other studies show a high prevalence of abuse among the elderly, the number of reports made to the Ombudsman has been declining every year. The reduction in the number of reports of other forms of abuse may be due to the failure to recognise these forms of abuse, both by the elderly, as well as their relatives and medical staff. Many forms of abuse are ignored or seen as normal everyday behaviour or communication. Although most of the reports are made by the elderly, these reports account for less than half of all reports. Given that the NORS has been set up primarily to investigate reports of abuse made by the elderly, these numbers indicate that the elderly are not sufficiently aware of their rights and do not know whom to turn to for help (Bloemen et al., 2015).
An analysis of trends in reports made to the Ombudsman about abuse and neglect of elderly residents in the institutional setting between 2006 and 2013 showed that the Ombudsman received an average of 11,749 reports per year. Every year, physical abuse was the most frequently reported type of abuse, representing 28% of total complaints over an 8-year period. Reports were most often made by the elderly residents themselves (38%), their relatives or friends (20%), while 17% of the reports were made by nursing home staff. The reports were resolved satisfactorily in 60% of the cases, unsatisfactorily in 6% of the cases and in 5% the report was handed over to another organisation (Bloemen et al., 2015).
Magruder et al. (2019) focused on analysing 140,497 reports of abuse from 3,171 long-term care facilities in Texas over the 2010-2017 period. The reports analysed were related to 1,940 assisted living facilities and 1,231 nursing homes. Elderly people in assisted living programs reported abuse in 16% of the cases. Psychological abuse (28.4%) was the most frequently reported form of abuse, followed by financial abuse (23.46%), physical abuse (14%), neglect (11.6%), and sexual abuse (5.56%). The total number of reports relating to abuse or neglect in nursing homes was 1,823. Elderly residents mainly reported being subjected to psychological abuse (34.78%), followed by physical abuse (19%), neglect (6%), and sexual abuse (5.32%), which was the least reported form of abuse.
Lacher et al. (2016) identified 150 of a total of 903 reports of at least one form of abuse or neglect in an analysis of reports submitted to an Independent Complaints Authority for Old Age in Switeerland. Almost 70% of cases were categorised as at least one form of abuse, and 30% were categorised as neglect, with 84.7% of cases constituting active neglect. About 43% of the victims lived in nursing homes, and the rest lived in their apartments. On average, the victims were subjected to abuse for a period of 3 months. The most commonly reported forms of abuse were psychological abuse (47%), followed by financial abuse (35%), physical abuse (30%) and unconstitutional abuse - abuse of constitutional human rights, e.g. theft of identity documents (18%). Women were subjected to abuse more often than men. Those who experienced abuse were more likely to live in
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a domestic environment, and victims of neglect were more likely to live in an institutional environment. The authors identified 14 risk factors associated with abuse. They were divided into two groups: a) risk factors related to victims (need for support, need for care, history of violence, aggressive behaviour, dementia, addiction, other psychiatric disease, social isolation); b) risk factors associated with the perpetrators (overload, cohabiting with the victim, dependence on the victim, addiction, other psychiatric disease, dementia). In 87% of the cases, at least one of the listed risk factors was identified, and on average, three risk factors were identified per case. The most common risk factors for victims were the need for support (73%), the need for care (59%) and dementia (41%). The risk factors that were associated with a higher risk for abuse than for neglect were the victim's existing history of violence, cohabitation of the victim and perpetrator, the perpetrator's overload, the perpetrator's dependency on the victim and dementia, or the perpetrator's psychiatric disease. The perpetrators were family members - (46%) partners (17%), sons (14%), daughters (8%) and other family members (7%), 37% of the perpetrators were professional caregivers and 11% were trading companies. The most common risk factors related to the perpetrators were being overburdened with the situation and cohabiting with the victim (33%). In 17% of reported cases, the perpetrator was economically or emotionally dependent on the victim. The perpetrator's overload more often led to neglect than to abuse.
In addition to the empirical papers presented, the systematic literature review also identified a paper that contains a systematic review of literature on elder abuse in nursing homes. Yon et al. (2019) found that elder abuse in the institutional setting has not received equal attention or priority treatment in the public health system compared to other forms of abuse. There is a significant gap in research focusing on this issue. The authors focused on the incidence of abuse over the past year. 55 studies were selected for review, 9 of which were included in the analysis. These studies provided data for staff-to-resident abuse. Four studies examined the prevalence of elder abuse reported by the victims (Czech Republic, Israel, Slovenia and the United States), including one where abuse was reported by someone else (close relatives) and one where abuse was reported by the elderly and the caregivers. In comparison, five studies examined the prevalence of abuse reported by employees (nursing staff). Of the studies on abuse reported by the victims, 64.8% - 82.8% of the victims were female. Women, on average, have a higher life expectancy than men and account for the bulk of the sample in most studies. In two studies, 75% of individuals over 75 years of age were included in the sample. The individuals who participated in the studies could orient themselves in time and space, however, most of them required assistance in activities of daily living. Residents reported being subjected to psychological abuse in the majority of cases (33 %), followed by physical abuse (14.1%), financial abuse (13.8%), neglect (11.6%), and sexual abuse (1.9%). There was an increased risk of elder abuse associated with declining health and with needing assistance in activities of daily living. In studies on abuse reported by the staff, they were asked if they had ever perpetrated elder abuse. The majority of participants (80% - 97%) were women. 62.4% of staff admitted to elder abuse. Staff reported two main stressors - staff shortages and time pressure. Staff who self-reported committing abuse described
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themselves as emotionally exhausted. The findings of the studies showed that an increased presence of qualified nurses was associated with a reduction in elder abuse risk. The authors point out that elder abuse in the institutional setting needs to be given greater attention and more resources. In order to provide adequate care for the complex needs of older residents, proper support must be provided to staff through training, education, and adequate human resources and wages.
4 DISCUSSION
The paper presents a systematic review of scientific papers published over the last ten years to assess the state of research on the topic of elder abuse. A total of 29 papers were included in the review, which were divided into four content sets according to the topic - papers that: (a) examine the incidence of elder abuse in nursing homes, (b) examine the incidence of elder abuse in ambulatory care facilities and emergency departments, (c) examine the incidence of elder abuse in the domestic environment, and (d) analyse complaints about violations of the rights of the elderly. To our knowledge, this analysis is one of the rare examples to analyse studies on abuse of the elderly as one of the most vulnerable demographics.
Although some countries have mechanisms in place to address abuse and elder maltreatment, such as laws criminalising elder abuse, prevention programs that encourage the disclosure of abuse, complaint mechanisms, and the Ombudsman's long-term care programs, there are very few countries that try to systematically assess whether long-term care is safe, efficient and meets the needs of the recipients of care. This is particularly important given the demographic challenge of an ageing society throughout the world.
Based on a review of the existing literature, we find that elder abuse is an under-researched topic in both institutional and domestic settings. The literature review shows that empirical studies analyse either reports or self-reports by the elderly on experiencing abuse or reports by nursing staff and family members of the elderly on perceptions of elder abuse. In terms of content, studies focus on the incidence of various forms of abuse, its perpetrators and risk factors. Results show that rates of psychological abuse, neglect and physical abuse are high in nursing homes and among older visitors to ambulatory care facilities and emergency departments, while self-neglect, neglect and psychological abuse are prevalent in the home environment. Complaints to the Ombudsman most often report physical, psychological and financial abuse, as well as neglect. Single or widowed women between the ages of 70 and 75, who are socially isolated and require daily care, are more exposed to abuse. The perpetrators of the abuse are most often family members (daughters-in-law, partners and children).
Detecting and investigating elder abuse cases is exceptionally challenging, especially when it comes to types of abuse that are highly sensitive by their very nature, such as sexual abuse. Gathering evidence is the biggest challenge, as confirmed by a study by Smith et al. (2019). Teaster et al. (2015) found that in almost 70% of reported cases of sexual abuse, it was not possible to confirm that the abuse did occur due to contamination or lack of solid evidence. The authors
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of these studies also highlight that many cases of abuse are not reported to the appropriate authorities, and the elderly are afraid to speak up about experiencing abuse.
The majority of the studies were conducted in developed, high-income countries, while studies from other parts of the world are few to non-existent. Due to differences in the conceptualisation of abuse in different societies, the different methods and tools used to study this phenomenon, and the different time frames, there are significant discrepancies in the findings of the studies. We did not find any papers from Slovenia among the literature reviewed, which also indicates a lack of studies on the topic in Slovenia. A systematic review of the literature has highlighted some other research gaps. Most research is quantitative, while there is a lack of qualitative studies to provide further in-depth understanding of the issue. There are also very few studies on elderly abuse in home setting or research examining the mechanisms of assistance, reviews by country, method or adequacy of how reported cases are investigated. There is also little research on the psychological consequences of abuse or abuse in different communities or living environments (e.g. rural, urban). This indicates that the research to date has narrowly focused on the types of abuse and risk factors, while other aspects that need to be understood to plan an integrated prevention and response program remain neglected in terms of research.
Future research should focus on elder abuse in the institutional and home setting. The population, the types of abuse (such as elder abuse by employees, resident-to-resident maltreatment in nursing homes and elder abuse by relatives) and the characteristics of institutions (such as staff-to-resident ratio, the number of qualified nursing staff) should be clearly defined. Detailed research methodologies should be adopted, particularly regarding sampling procedures, and the use of standardised measurement tools for data collection should be specified (e.g. inperson interviews with the elderly, staff questionnaires, the Hwalek-Sengstock Elder Abuse Screening Test and the Elder Abuse Suspicion Index). Greater emphasis should also be placed on developing more unified and systematic strategies to manage the quality of nursing home care, which could provide more regular and systematic data collection for future research.
Researchers (Neuberg et al., 2019) also often point to the importance of changing care staff behaviour towards the elderly residents, which is often rude and indifferent. The threat of sanctions against staff does not seem like an appropriate solution, which is why measures such as education, training and motivating caregivers to work with care recipients and developing standardised care procedures are critical factors in improving resident satisfaction, quality of care and reducing conflicts in institutions. §en and Meric (2019) also believe that training is needed to raise awareness of the elderly, who are at greater risk of becoming victims of abuse, the various forms of abuse and where victims and witnesses can turn for help. It would be helpful for medical staff to assess the incidence of depression during medical examinations of elderly patients. More frequent visits to home care units and a more robust social network can significantly contribute to preventing violent behaviour against the elderly. Health professionals (especially community nurses), who are often the first to encounter
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the elderly, should be aware of any risk factors in order to identify abuse and take appropriate action successfully (Lacher et al., 2016). A multidisciplinary approach to recognising and preventing elder abuse in the domestic environment is also needed.
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About the Authors
Teja Prime, PhD student at the Faculty of Criminal Justice and Security, University of Maribor. E-mail: teja.primc@student.um.si
Branko Lobnikar, PhD, Professor, Faculty of Criminal Justice and Security, University of Maribor. E-mail: branko.lobnikar@fvv.uni-mb.si
Kaja Prislan, PhD, Assistant Professor, Faculty of Criminal Justice and Security, University of Maribor, Slovenia. E-mail: kaja.prislan@fvv.uni-mb.si
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