Global Review of Elder Mistreatment Research
A Narrative Review
Abstract
Abstract: Elder mistreatment (EM) is a global phenomenon, affecting an estimated 1 in 6 older adults. It is associated with many negative consequences, including worsening physical and mental health. The present work presents a narrative review of the prevalence and incidence of EM from 2014–2022. The studies included provided evidence of prevalence or incidence of elder abuse at national or subnational levels of at least one type of EM, though most studies often report rates of many types of EM. Overall, we retained 35 studies, comprising 41 different prevalence or incidence rates across five continents. The rates of EM varied widely both within and between countries. While less studied, we also present incidence rates, the rates of elder-on-elder mistreatment in institutional settings, and the rates of mistreatment by caregivers and discuss interventions and policy implications.
Elder mistreatment (EM) is a serious international problem that has seen significant growth in the literature over the past decade. EM is defined as intentional actions which cause harm or create a serious risk of harm to a vulnerable older adult, failure to meet the basic needs of the older adult, or failure to prevent harm (National Research Council, 2003). Given the severity and scope of this problem, this research focuses on providing a bird’s-eye view of the global situation of EM prevalence research.
Many international organizations have highlighted the impact of EM globally and stress the need for future research. For example, the World Health Organization (WHO) has stated that the worldwide prevalence of EM is approximately 16%, that rates of EM are high in institutional settings, and that EM is associated with serious physical injuries and long-term psychological harm (World Health Organization, 2021). Moreover, EM was highlighted in the WHO World Report on Ageing and Health document as a key environmental risk facing older adults (World Health Organization, 2015). In response, and in line with the WHO global strategy and action plan based on aging and health, the WHO seeks to collaborate with others to prevent EM through initiatives designed to identify, quantify, and respond to the problem.
Similarly, the United Nations (UN), in collaboration with the WHO’s mission, has planned a similar response in the UN Decade of Health Aging (2021–2030), describing EM as an overlooked and underdiagnosed problem. The UN has also made 15 June Elder Abuse Awareness Day. EM is expected to gain increasing relevance as the worldwide population continues to age, with an increase of 38% in the number of older adults (60+) over the next decade, from one billion to 1.4 billion (UN), with an increase to 2 billion by 2050 (United Nations, 2022).
Previous work has demonstrated the global scope of this problem in a review that covered through 2014 (Pillemer et al., 2016), with evidence of incidence, prevalence, risk factors, consequences, and prevention strategies. A meta-analysis examined EM globally through 2015 (Yon et al., 2017), with a pooled prevalence estimate of global abuse of 15.7%. This article provides an updated narrative review on the prevalence and incidence of EM across the world from 2014–2021, to build upon the previous work and demonstrate the increasing scope and complexity of the problem.
Method
Narrative reviews are helpful in presenting a broad overview of a topic, showing the history and development of a topic over time through a search of the relevant literature. Similar to Pillemer and colleagues (2016), we examine incidence and prevalence studies from around the world. However, in this review we are more inclusive in our inclusion of prevalence and incidence studies, to better demonstrate the scope of the problem and describe the amount of research being done in this area worldwide.
One primary difference between this review and that of Pillemer and colleagues (2016) is that the present article does not restrict studies to representative samples. Additionally, studies need not be confined to community settings, as this review examines research among special subpopulations of older adults, such as those with dementia or who are in an institutional setting. The review includes studies conducted on city/regional populations as well as national samples.
Inclusion Criteria and Article Selection
Inclusion criteria include a measure of EM prevalence or incidence within a defined geographic area, no larger than the country level. The prevalence of EM was measured as the occurrence of one or more acts that constitute EM, that are acts that harm or create a risk of harm for an older adult, or that neglect to provide for the basic needs of older adults since age 60. Many studies contain general prevalence estimates of EM, or EM since age 60, while others specify a more specific time period, such as the past year (see Table 1). Additional criteria include participants being older adults, defined as 60+, and EM must be defined and measured in each study. Further, studies must include the sample size on which the prevalence or incidence rate is based. Meta-analyses of abuse by country are excluded as they provide redundant information. Studies that do not provide prevalence or incidence rates were not included. Where possible, we examine EM by subtype (physical, psychological/emotional, sexual, financial, or neglect) and at the aggregate level. Moreover, we extract explanatory factors which may be related to the prevalence or incidence of EM.
We used the following search terms: “elder mistreatment OR elder abuse” AND “incidence OR prevalence,” and only included studies with abstracts and full texts, to allow for examination of the study to determine eligibility, as described above. This search returned 246 records. The initial screening of titles and abstracts for inclusion in the present study reduced this number to 96. In-depth readings of abstracts and articles to screen for eligibility reduced the sample to a final number of 35 publications comprising 41 prevalence or incidence rates across 24 regions/countries, including at least 133,279 participants across included studies. Most countries contained only one estimate, while a minority, such as the United States, Iran, and India, had many estimates of prevalence. Moreover, most of the studies measured EM prevalence, with only two studies reporting the incidence of EM.
Results and Synthesis
Prevalence
Data on the prevalence rates of EM worldwide as well as rates for the subtypes of abuse are presented in Table 1. The data show high variability in estimates of EM across the world, from a high of 79.6% in Iran (Morowatisharifabad et al., 2016) to a low of 4.5% in Malaysia (Sooryanarayana et al., 2017). Moreover, much of the research is at the national level, spanning 5 continents and 24 countries, though a small minority captures EM at a subnational level, particularly in the United States, Iran, and India. Finally, a small body of work has begun to examine prevalence rates in specialized populations such as resident-to-resident EM in institutional settings and EM among dementia family caregiving dyads.
Although most studies report an overall prevalence rate for abuse, many report on the five recognized subtypes of abuse. Physical abuse, emotional/psychological abuse, and financial abuse appeared most frequently, while sexual abuse and neglect were less often studied. Physical abuse rates ranged been 0.05 among two populations (Carmona-Torres et al., 2020; Sooryanarayana et al., 2017) to a high of 26.8% in another sample (Aslan & Erci, 2020). Rates of psychological and emotional abuse ranged from 0.6% (Leung et al., 2017) to a high of 65% in another sample (Kaur et al., 2015). Financial abuse occurred at rates between 1.3% (Curcio et al., 2019) and 47.4% (Fraga Dominguez et al., 2021). Rates of sexual abuse ranged from 0.1% (Sooryanarayana et al., 2017) to a high of 12.6% (Aslan & Erci, 2020). Finally, neglect was reported in a range from 0.8% (Fraga Dominguez et al., 2021) to 57.5% (Yadav et al., 2018). One study reported a high rate of neglect (66.5%; Kaur et al., 2015), but it measured only social neglect, without reporting on other forms of neglect, such as physical and emotional neglect. As can be seen, there is wide variability in the estimates of EM prevalence.
The variability in rates may reflect actual differences in prevalence rates of EM among and across countries, though an examination of methods reveals that some of the variability may result from differences in measurement. The most common measure of EM prevalence was questionnaires created by the research teams, not one of the validated EM scales. Among validated instruments, the HS-EAST was the most common measure, whereas other studies used the Conflict Tactic Scales-Revised, VASS, and EASI. Because of a lack of standardized measures for financial abuse of older abuse, all prevalence data for this construct were collected through nonvalidated or unstandardized instruments. Recent work is beginning to address this problem by creating standardized measures of financial abuse of older adults for use in prevalence and incidence research (Beach et al., 2017; Hancock et al., in press). Other notable sources of variation among prevalence studies include sample size and types of EM measured. Some data represent large representative samples, including over 20,000 participants, while some are more modest with around 200 participants. Physical and psychological/emotional abuse were the most commonly measured, with prevalence rates reported twice as often as rates of sexual abuse or neglect.
Incidence
Only two studies examined the incidence of EM, both from the United States (Burnes et al., 2021; Dong & Wang, 2017). Incidence research is more difficult to carry out as it requires longitudinal measurement of EM. In one study, the 10-year incidence of EM was 11.4%, with the most common form of incident EM being financial abuse or exploitation of older adults (8.5%, Burnes et al., 2021). Among a Chinese-American sample, the 2-year incidence was 8.8%, with physical abuse the most common subtype, with an incidence of 4.8% (Dong & Wang, 2017). Both studies demonstrate that cross-sectional measures of prevalence likely underestimate levels of EM, as incidence research demonstrates a significant minority of the population will consequently become victims of EM if measured over more than a single time point.
Risk Factors
Risk factors for EM described in the literature fall generally into three domains. Some risk factors are related to the victims of abuse, some are related to the perpetrator of abuse, and others are related to the interpersonal and social situations in which an individual is located.
Many individual, victim-level risk factors were supported in the literature, as indicated by the most significant relationships among the study population. A common risk factor is being female (Acharya et al., 2021; Alizadeh-Khoei et al., 2014; Carmona-Torres et al., 2020; Curcio et al., 2019; Kaur et al., 2015; Koga et al., 2020; Ribot et al., 2015). Additionally, poor physical health is associated with an increased risk of EM (Acharya et al., 2021; Alizadeh-Khoei et al., 2014; Blay et al., 2017; Burnes et al., 2015; Cevik et al., 2021; Koga et al., 2020; Leung et al., 2017; Melchiorre et al., 2016; Sooryanarayana et al., 2017). Poor mental health was also demonstrated as a risk factor for EM (Blay et al., 2017; Chokkanathan, 2018; Fraga Dominguez et al., 2021; Koga et al., 2020; M. Lee & Kim, 2014; Melchiorre et al., 2016; Sooryanarayana et al., 2017). Finally, low socioeconomic status (SES) was associated with increased risk at the victim level. Factors indicative of low SES were poor finances, illiteracy, and low education. For example, poor finances were often cited as a risk factor (Acharya et al., 2021; Alizadeh-Khoei et al., 2014; Burnes et al., 2015; Cevik et al., 2021; Chang & Levy, 2021; Du & Chen, 2021; Kulakçı Altıntaş & Korkmaz Aslan, 2020; Mohseni et al., 2019). Additional studies noted the role of illiteracy (Acharya et al., 2021; Carmona-Torres et al., 2020; Hosseinkhani et al., 2017; Kulakçı Altıntaş & Korkmaz Aslan, 2020; Yadav et al., 2018). Finally, low education was demonstrated as an individual, victim-level risk factor (Blay et al., 2017; Cevik et al., 2021; Curcio et al., 2019; Du & Chen, 2021).
Although many sources support these risk factors, some studies are inconsistent. For example, Melchiorre and colleagues (2016) and Sooryanarayana and colleagues (2017) found that males were more likely to be victims of EM. Other research demonstrated financial security or independence (Dong & Li, 2015; Kaur et al., 2015; Saikia et al., 2015) and more education (Dong & Li, 2015; Melchiorre et al., 2016) as risk factors for EM. The relationship between age and EM is unclear. Although much research indicates that the oldest adults are more likely to be victims of EM (Du & Chen, 2021; Kaur et al., 2015; Kulakçı Altıntaş & Korkmaz Aslan, 2020; Ramalingam et al., 2019; Saikia et al., 2015), some research found younger individuals to be at risk (Burnes et al., 2015; Morowatisharifabad et al., 2016; Sooryanarayana et al., 2017). These discrepancies are worthy of further investigation and likely result from differing definitions, sociocultural factors, and sampling strategies.
Although less well studied than risk factors, some factors serve to protect an individual from risk of EM victimization. These protective factors typically correspond to factors associated with greater risk. Given that poor education is a risk factor, it is not surprising that research has demonstrated greater education to be protective against EM (Du & Chen, 2021; Ramalingam et al., 2019; Skirbekk & James, 2014). Other protective factors include religious beliefs (Du & Chen, 2021) and being in better health (Mohseni et al., 2019). Although the relationship between age and EM is unclear, multiple studies have identified advanced age as a protective factor (Hosseinkhani et al., 2017; Koga et al., 2020; Melchiorre et al., 2016). This may be because advanced age is associated with an increased likelihood of being widowed or unmarried, removing potential abusers from the situation.
Although less of a research target, some perpetrator-level factors may increase the risk of EM perpetration. Being an adult son is a risk factor for higher levels of EM perpetration (da Silva Santos et al., 2021; Fraga Dominguez et al., 2021; Saikia et al., 2015; Skirbekk & James, 2014). Other factors related to increased perpetration of EM include poor mental health and substance abuse (da Silva Santos et al., 2021; Fraga Dominguez et al., 2021; Leung et al., 2017). Additionally, poor physical health (Fraga Dominguez et al., 2021) and problematic attitudes, such as ageism or unrealistic expectations of the victim, were other potential risk factors (Fraga Dominguez et al., 2021).
Several aspects of the social environment affect the risk of EM. Such factors include lack of social support (Kulakçı Altıntaş & Korkmaz Aslan, 2020; Sooryanarayana et al., 2017) and loneliness/social isolation (Acharya et al., 2021; Chokkanathan, 2018; Sooryanarayana et al., 2017). Moreover, having more children (Du & Chen, 2021; Skirbekk & James, 2014) and not owning one’s own home (Kulakçı Altıntaş & Korkmaz Aslan, 2020) are additional social factors that increase the risk of EM victimization. Community-level protective factors include increased social support (Koga et al., 2020; Melchiorre et al., 2016), social cohesion, increased views of community trust (Koga et al., 2020), participating in social activities, cohabiting with a spouse (Du & Chen, 2021), and sense of community (Chang & Levy, 2021).
At the national or regional level, several factors are related to the risk of EM victimization, though the evidence is mixed. Rural and urban areas have both been found to predict risk, though a subgroup analysis demonstrated this difference stemmed from the type of abuse, finding that physical abuse was more common in rural areas and all other types of abuse more common in urban areas (Cevik et al., 2021; Curcio et al., 2019; Kaur et al., 2015). Another factor involves social standing, namely, the social class to which one belongs. Social standing is especially important in India, where the social caste in which one is a member can increase risk, especially among lower-caste members (Acharya et al., 2021; Skirbekk & James, 2014).
Given the limited research on EM incidence, much less is known about potential risk and protective factors related to EM incidence. Available evidence suggests greater age, being female, and poor health (Dong & Wang, 2017) may increase risk among Chinese-American samples, while poor health, race, and a change in the living situation were associated with greater risk of EM among a sample of older adults from New York (Burnes et al., 2021).
Special Populations
EM has been studied within two special populations: older adults residing in institutional settings and older adults with dementia and their caregivers. Prior research indicates that EM is common in institutional settings. Indeed, nearly two out of three employees at such institutions report committing at least one act that would constitute EM (Yon et al., 2019). Among the studies surveyed here, the focus was on EM perpetrated by other residents, not by paid staff. Among an Australian sample, the prevalence rate of resident-on-resident EM (R-REM) was 7.6% (Joyce, 2020). Further, among a sample from New York, in the United States, the overall prevalence was 20.2%, with a prevalence of 9.1% for psychological/emotional abuse, 5.2% for physical abuse, and 0.6% for sexual abuse (Lachs et al., 2016). Individual-level risk factors included mild (rather than severe) cognitive impairment and better physical health. Communal-level risk factors included residing in a dementia unit or a unit with a higher nurse aid caseload. Moreover, perpetrators of R-REM were more likely to have a cognitive impairment themselves (Joyce, 2020; M. S. Lachs et al., 2016).
A recent review reports an estimated EM prevalence range of 27.9–62.3% among persons with dementia, which is higher than in the community samples. Moreover, this review suggested that individuals with dementia were likely to be victims of more than one type of EM, and that EM may be associated with greater mortality among those with greater cognitive impairments (Dong et al., 2014). Rates of EM are generally higher among dementia caregiving samples. In one study, the prevalence rate of any EM was 42.3% (Yan, 2014) and in another sample (Wang et al., 2019) ran as high as 77.8%. Risk factors for EM among dementia caregiving dyads were related to perceptions of support, caregiving burden, male CR, and agitated behaviors by the CR (Wang et al., 2019; Yan, 2014; Yan & Kwok, 2011).
Prevention
Among the most pressing needs in the field of EM, and the greatest gap in the extant literature, are interventions to prevent EM (Pillemer et al., 2016). In the research articles selected for the present study, after describing the scope of the problem, some offer suggestions on ways to reduce EM. Most of these suggestions involve policy changes at the community or societal level. Recommendations include increased community awareness of EM, educational interventions to increase awareness and provide strategies to avoid EM, and making health services more accessible (Acharya et al., 2021).
Given the high prevalence of EM, increased awareness can shine a light on this problem that has largely been neglected or characterized as “under the radar” (Lachs & Berman, 2011). Other suggestions include increased government assistance and public health and social policies to improve relationships (Acharya et al., 2021; Cevik et al., 2021). Given the relationship between health, SES, and EM perpetration/victimization, these policies could increase individual health and improve SES, which may prevent the occurrence of EM.
Interpersonally, interventions that strengthen family relationships or increase the sense of community may serve as protective factors against EM perpetration (Acharya et al., 2021; Cevik et al., 2021). A common target for interpersonal interventions to reduce EM include interventions designed to support caregivers of older adults by reducing the burden, by providing vital services such as education, support groups, and housekeeping or meal prep (Pillemer et al., 2016).
Another solution that has clinical relevance is using multidisciplinary teams to treat older adults, bringing together experts from many fields including geriatricians, social workers, nonprofits, and the justice system (Hosseinkhani et al., 2017). For a multidisciplinary team to be successful, numerous services need to be accessible, such as nonprofits, a functioning justice system, doctors, and social workers, which at present may only be possible in high-income, developed countries. Previous reviews suggested additional intervention targets, including helplines, emergency shelters, and money management programs (Pillemer et al., 2016).
Conclusion
EM is a global problem. Emerging research has examined the prevalence of EM in many countries worldwide. The best global estimate of EM suggests that 1 in 6 older adults are victims of EM (Yon et al., 2017). Given this information, increased awareness of the prevalence, incidence, and risk or protective factors is necessary. The present work highlights growth in these areas, while also revealing areas of need.
Levels of EM varied substantially within and between regions. This variation is likely for several reasons. First, these differences may represent actual differences between regions. Second, the studies varied considerably in methods. We were relatively generous with our inclusion criteria, to better demonstrate the scope of research, which introduced additional variance because of diverse methodologies. Some studies contained 200 participants, while others included thousands (see Table 1). Indeed, as the number of participants increased, the prevalence or incidence of EM generally decreased (rSpearman = −.39, p < .01). Moreover, studies had different definitions of older adults. Most studies considered 60 years the age criterion, whereas some considered 65 years (see Table 1). Additionally, studies used varying measures of what constitutes EM. The most common measure of EM was a count of the occurrence of one or more events that may constitute EM. Finally, studies differed in the time period in which the EM occurred, such as yearly or since age 60. Notwithstanding these limitations, the present research demonstrates that EM is a significant public health problem that is beginning to be recognized globally, as demonstrated by the scope of the studies included in the present study.
Although many nations have begun to examine the prevalence of EM, these studies are concentrated in large, high-resource countries. Little research has been done among low and middle-income countries, with a noticeable lack of evidence coming from Africa. Moreover, the prevalence rates are often based on unvalidated measures, with little agreement on how to properly assess prevalence, even with the use of established measures.
Further, more work needs to be done to create standardized measures of EM, to better facilitate comparisons between studies. Almost no research has examined the incidence of EM or its associated factors. As such, an increase in longitudinal studies is necessary to establish more incidence research to better understand the temporal relationships between risk factors and EM. Improving the research base is critically important to preventing and treating EM worldwide.
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