Elder Abuse: A National Disgrace. A Report by the Chairman of the Subcommittee on Health and Long-Term Care of the Select Committee on Aging, House of Representatives, Ninety-Nineth Congress, First Session; May 10, 1985. U.S. Government Printing Office, Washington.

Why we need a shared definition of elder abuse, in context

My grandmother’s case gained national attention. Most elder-abuse cases are not even known. Only one in 24 cases of elder abuse are reported and only one in 44 cases of elder financial exploitation (the most prevalent form of abuse) are reported — as detailed in Under the Radar (2011).

Mark S. Lachs and Karl A. Pillemer (2015, 1949) note,

“When the available evidence is taken into consideration, an estimated overall prevalence of elder abuse of approximately 10% appears reasonable.”

Over a year, one in ten older citizens are victimized by one or more of the five major types of elder abuse: financial exploitation, physical abuse, psychological or emotional abuse, neglect, and sexual abuse.

Elder abuse is a pervasive, profound, and systemic social problem that cannot be understood or addressed effectively from within its own confines. No system can define its own axioms, which are gained at a greater level. Elder abuse is more constructively viewed through the lens of elder justice that, in turn, must be viewed through the lens of justice, cradled by trust.

To understand elder abuse and exploitation as a violation of our social compact, as a systemic social harm, as a betrayal of trust, and as a crime, it is vital to examine first how society views elder abuse before advancing to elder justice.

Vicki Gottlich (1994, 371, fn. 1) chronicles:

“The term ‘elder abuse’ arose out of the first Congressional hearing on the issue, which was convened in 1978 in Boston, Massachusetts, by the House Select Committee on Aging. The now-defunct Committee attributes the phrase ‘elder abuse’ to the late Claude Pepper (D. Florida), then chairperson of the Aging Committee… Another source states that Legal Research and Services for the Elderly[1979] in Boston coined the term because of its ‘news media appeal.’”

At its essence, elder abuse is a betrayal of trust — aside from all too prevalent fraud (Office of Victims of Crime, U.S. DOJ) and “pure” elder financial exploitation (Shelly Jackson and Thomas L. Hafemeister 2012), which is typically associated with fraud by strangers.

As defined by the World Health Organization (WHO):

“Elder abuse…is a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person. This type of violence constitutes a violation of human rights.”

Elder abuse includes financial exploitation, psychological abuse and manipulation, deprivation, neglect (including self-neglect), isolation, abandonment, restraint (physical and chemical), and physical and sexual abuse.

Elder abuse is delivered and endured in many ways. Older citizens may be poly-victimized (enduring more than one form of abuse) and re-victimized. The forms, frequency, and duration of abuse may be intensified and escalated, especially when there is an intimate, long-term relationship between victim and perpetrator. This typically happens with hybrid financial exploitation, when various forms of abuse are strategically deployed to advance the perpetrator’s sinister goals.

Shelly L. Jackson and Thomas P. Hafemeister (2010, 11–12) conclude, among all forms of abuse, hybrid financial exploitation:

“…is perhaps the most entrenched (e.g., it is generally the longest in duration) and intractable (because it is characterized by mutual dependency between the elderly person and the perpetrator), the most difficult for APS [adult protective services] to investigate, and with the most draconian outcomes for the victims of this abuse (e.g., the victim is the most likely to be appointed a guardian).”

Jilenne Gunther, in the introduction of The Scope of Elder Financial Exploitation: What It Costs Victims (AARP Banksafe Initiative, 2023), cites her findings:

“Every year, millions of older Americans lose significant portions of their life savings to elder financial exploitation, and the problem is only growing. During the pandemic, the rate of exploitation doubled, and some pandemic-related forms of exploitation are here to stay.”

Elder abuse is a “serious public health problem” (CDC), a societal epidemic that spreads like a contagious disease. Naming a disease can be harmful, especially if it leads to stigma, discrimination, and society’s dis-ease. Calling something a disease is only beneficial if it guides proactive prevention and intervention — care and, when possible, a cure. New social norms will help reduce contagion and casualties.

Google Doodle, September 29, 2023; Mihály Csíkszentmihályi’s 89th Birthday

In our digital domain, the term elder abuse helps persons search for help or to help informed by rich resources found in programs and services provided by experts. For individuals who wish to expand their search libraries provide a safe, helpful space — highlighted by the Federal Depository Library Program and Consumer Financial Protection Bureau (November 14, 2023). In libraries, concerned persons can gain access to professional, peer-review research and resources, exemplified by the Elder Abuse LibGuide (Montana Board of Crime Control).

The term elder abuse advances policies (NCEA Elder Justice Policy Highlights, March-August 2023), statutes (compiled by the Elder Justice Initiative, U.S. Department of Justice), protocol (Christopher Mikton and colleagues, 2022) practices, and advocacy — when informed by peer-reviewed research (NCEA Elder Abuse Annual Research Compilation) and evidence- and value-based practices.

Above, value is employed, over cost-benefit. “Because many cost–benefit analyses are biased against older adults, innovative strategies are needed to capture the range of personal, community, financial, and societal costs of elder abuse,” observes Xin Qi Dong (June 11, 2015; 1233).

Yet, “There is no national consensus on a definition of elder abuse and state definitions vary widely,” concluded Lori A. Stiegel and Erica F. Wood in a paper published over a decade ago (2011, 1). This lack of consensus remains the case today, as exemplified by the wide range of definitions in elder abuse and elder financial exploitation statutes (EJI, DOJ).

The Centers for Disease Control and Prevention, published “Elder Abuse Surveillance: Uniform Definitions and Recommended Core Data Elements” (2016, 8), compiled by Jeffrey Hall and colleagues. They report,

“…longstanding divergences in the definitions and data elements used to collect information on elder abuse make it difficult to measure elder abuse nationally, compare the problem across states, counties, and cities, and establish trends and patterns in the occurrence and experience of elder abuse.”

Claudia Mahler reports (September 3, 2023; 3) on Violence against and abuse and neglect of older persons (Human Rights Council, United Nations General Assembly Fifty-fourth session (11 September to 6 October 2023). Under “definition” Mahler writes:

“There is still no globally accepted definition of ‘elder abuse’ or ‘abuse against older persons.’ Studies worldwide use different terms to address the topic. Such terms include ‘elder abuse,’ ‘violence against older persons,’ ‘elder maltreatment’ and ‘abuse and exploitation of older people.’ The use of different terminology brings other nuances to the fore.”

It is imperative we agree upon a consistent and comprehensive definition of elder abuse. Terms such as “mistreatment” and “maltreatment” (including NAMRS) minimize this social harm and society’s attempt to address it head-on. Dispensing with the term “elder abuse” would be worse. In 2018, pending the reauthorization of Violence Against Women Act various proposed amendments were considered, including one to remove “elder abuse” from the statute’s universal definition. It was retained (2022 VAWA Reauthorization).

In the future, a consistent definition of elder abuse will advance our understanding of prevalence, consequences, risks, protective factors, intervention, and proactive prevention.

This definition ought to be informed by a Campbell systematic review whose protocol was developed by Christopher Mikton and colleagues in “Protocol: Global elder abuse: A mega-map of systematic reviews on prevalence, consequences, risk and protective factors and interventions” (2022). The protocol’s objectives are “to produce a mega-map which identifies, maps and provides a visual interactive display, based on systematic reviews on all the main aspects of elder abuse in both the community and in institutions, such as residential and long-term care institutions.”

Figure 4: How Figures 1–3 are connected. (Figure 1: The four steps of the public health approach, Figure 2 Risk and protective factors organized according to the socio‐ecological model (Labrum & Solomon, 2015), and Figure 3: Framework for interventions to prevent, detect and respond to elder abuse.) Mikton, C., Beaulieu, M., Yon, Y., Genesse, J. C., St‐Martin, K., Byrne, M., Phelan, A., Storey, J., Rogers, M., Campbell, F., Ali, P., Burnes, D., Band‐Winterstein, T., Penhale, B., Lachs, M., Pillemer, K., Estenson, L., Marnfeldt, K., Eustace‐Cook, J., … Lacasse, F. (2022). PROTOCOL: Global elder abuse: A mega‐map of systematic reviews on prevalence, consequences, risk and protective factors and interventions. Campbell Systematic Reviews, e1227.

Elder abuse, in its various forms, can manifest as isolation by both society and an abuser. To effectively combat this social harm, the term elder abuse must not be isolated, too. By employing consistent terminology in a greater context, society can gain a deeper understanding of elder abuse’s intricate and multifaceted nature, enabling a more engaged and coordinated response.

SNOMED CT, the world’s most comprehensive clinical terminology and coding system, offers a detailed classification of elder abuse, enabling healthcare providers to document and identify specific forms of abuse with greater precision and nuance. This enhanced understanding facilitates accurate information exchange, guiding value- and evidence-based screening, assessment, assistance, coordination, referral, restorative care, and proactive prevention. SNOMED International is a not-for-profit organization that owns and maintains SNOMED CT, which plays “an essential role in improving the health of humankind by determining standards for a codified language that represents groups of clinical terms.”

Social Care 2021 Survey key result offering contexts (slide #6, modified). Social Care services are predominately provided within the Social Services system in Member countries. However, four Social Care services (i.e., home care/support & long term care, mental health, alcohol and drug misuse and services to people with learning and physical disabilities) are provided in both the health care and social service systems. Note 1: The percentage values indicate the percent of respondent countries where the specified Social Care service is provided within the Healthcare system (left value) and the Social Services system (right value). Note 2: This diagram is a generalization of the results from the 18 survey respondents and does not necessarily reflect the exact organization of Social Care within each country • Slide #4: Social care is defined as: the provision of social work, personal care, protection or social support services to children or adults in need or at risk, or adults with needs arising from illness, disability, old age or poverty… The exceptions were North America (U.S. and Canada), Norway and Switzerland. — Source: Social Care Future Directions (Powerpoint), September 2022, Jane Millar. SNOMED International: Delivering SNOMED CT.