Neglect, abuse and violence against older women: Prevalence data.

Patricia Brownell¹

¹ Fordham University, New York City, New York, USA.

Corresponding author: Patricia Brownell, PhD;
Address: Fordham University, New York City, New York, USA;
E-mail: brownell@fordham.edu.

Abstract
In spite of a general consensus in the international research community that domestic violence is a public health matter and knowing rates of prevalence and incidence in the population is useful, there is notoriously little consensus on these rates for elder neglect, abuse and violence. A review of the prevalence literature on neglect, abuse and violence against older women using diverse research frames, categorized as social gerontology or active ageing, adult protection, and intimate partner violence (IPV), provides insight into reasons for this lack of consensus.
This overview of the prevalence of neglect, abuse and violence against older women based on different and sometimes competing research frames demonstrates the difficulties in using these data to understand and promote older women’s right to live lives of dignity, free of abuse. In order to address the current fragmentation in research on older women and neglect, abuse and violence, the international research community must come together to formulate guidelines that standardize measures, eliminate ageist views, and reflect a more holistic perspective on older women in society.

Keywords: abuse, neglect, older women, violence.

Introduction
In spite of a general consensus in the international research community that domestic violence is a public health matter and knowing rates of prevalence and incidence in the population is useful, there is notoriously little consensus on these rates for elder neglect, abuse and violence (1). A review of the prevalence literature on neglect, abuse and violence against older women using diverse research frames, categorized as social gerontology or active ageing, adult protection, and intimate partner violence (IPV), provides insight into reasons for this lack of consensus.

Definition of prevalence and incidence
The concept of a prevalence or incidence rate is generally applied to disease. Prevalence refers to the number of cases of a disease in existence at any stage of its development but short of death, during a particular time period in a given population. By comparison, incidence rate is defined as the number of new cases in a given population occurring within a specific time period (2). Prevalence and incidence rates have long been used in the realm of diseases to describe behavioral attributes, such as substance abuse, delinquency, and domestic violence.

Prevalence research on neglect, abuse and violence of older women
Prevalence research has been done on mistreatment of older adults, particularly in developed countries. Most of this research has focused on older adults generally, and little of the data collected has been fully disaggregated for both females and males. There are three research frames most commonly used in prevalence research on neglect, abuse and violence against older women: social gerontology or active ageing; intimate partner violence (IPV); and adult protection.

Prevalence research and Social Gerontology or active ageing: neglect, abuse and violence against older women
Social gerontology or active ageing: This research frame uses the Toronto Declaration definition of abuse (3), and a broad definition of the relationship between older victim and abuser, who can be a spouse/partner, an adult child or grandchild, another relative, a friend or neighbor, or a formal or informal caregiver. It also leaves open the setting in which the harmful or distressful act or acts may take place (home or community, institution, or workplace), as well as the forms of the abusive act or acts (physical, sexual and emotional abuse, financial exploitation, and neglect).
The age of victim/subjects is typically set at 60 years of age and older. The victim/subject is usually community dwelling. While establishing old age at 60 years and above and focusing on community dwelling older adults is not without controversy, generating debates on when old age begins and raising concerns about under-sampling of older adults with significant impairments, this has the advantage of providing a relative standardization for the age range and living arrangements of victims studied.
Abuse or mistreatment is operationalized as including not only physical, sexual, and psychological abuse (broadly defined), but also financial exploitation, neglect, and, increasingly, control and quality of life. Physical abuse is often measured using the Conflict Tactics Scale 2 (CTS2). While this research paradigm is the most inclusive of those discussed here, it has the disadvantage of under-sampling and under-estimating abuse and neglect of older women who are not only care dependent, but also cognitively incapacitated and living in institutional settings. This makes findings on abuse of older women difficult to compare with studies of abuse in institutions like care facilities, or with subjects suffering from dementia and receiving in-home care.
Data collection in the social gerontology frame has been done primarily through direct telephone and in-person interviews, in addition to mailed questionnaires and some use of third party sources, and findings are generally based on self-reports of abuse or neglect. The most significant research on older women and abuse in this research paradigm has been done in the European Union, where a research initiative on older women and abuse was recently completed as part of the DAPHNE III initiative. Utilizing world-class elder abuse scholars and experts, a multi-nation research program was undertaken that has resulted in establishing prevalence rates for women 60 years of age and older in five European countries using a common definition, standardized data collection instruments and analytic techniques, and intersecting research teams (4).
From the DAPHNE III initiative in the EU, overall abuse prevalence rates for older women age 60 years and above reported by countries that participated in the prevalence study (Austria, Belgium, Finland, Lithuania, and Portugal) are: Neglect: 5.4; Emotional: 23.6; Financial: 8.8; Physical 2.5; Sexual: 3.1; Violation of personal rights or social control: 6.4; and Overall abuse: 28.1 (4).
Prevalence of abuse by category of perpetrators in the DAPHNE III research initiative differs by type of abuse. For physical and sexual abuse, as in IPV studies on adult women of all ages, the spouse/partner is the most prevalent category of abuser (50.7 and 55.4 respectively). The spouse/partner continues as the most prevalent category of abuser for emotional abuse (43.9) and violation of rights (59.0). For financial abuse, while the spouse/partner remains the most prevalent category of abuser (33.7), it is closely followed by the category of Daughter, Son, Son and Daughter in-law (28.7). For neglect, however, Son and Daughter or Son/Daughter in law, is the most prevalent category of abuser (40.6), followed by spouse/partner (17.3), paid home help or caregiver (15.8), and other family members (15.5) (4).

Prevalence research: intimate partner violence (IPV) and older women
Prevalence studies on IPV and older women tend to fall into three general categories: studies of IPV and older women only, often using health data files from which to draw samples; studies of IPV across the lifespan (starting at age 18 or earlier, with the lowest age at 12) for women only; or population studies across the lifespan using gender as a variable (both males and females). For those few studies that actually disaggregate data collected by age and gender, old age can be defined as starting as low as 30 years of age, up to 65 years and older. In some studies data are not collected on women over the age of 49, leaving out older women altogether (5). In other words, the older women cohort can vary considerably by size and age distribution depending on how individual researchers define old and if they even include older women in their samples.
One distinguishing factor with studies on IPV and older women is how IPV is operationalized based on form of abuse. Internationally, IPV research studies typically use some variation of the United States of America (USA) Centers for Disease Control (CDC) definition of domestic violence (6). This includes at minimum physical and sexual abuse, with psychological abuse limited to threats of physical or sexual violence, and in the expanded definition of psychological abuse, verbal and other forms of abuse intended to intimidate the victim and diminish the victims’ self of self. If financial mistreatment is included at all, it is as part of the psychological abuse category. Measures of violation of personal rights or social control may be included as a separate form of abuse or as part of psychological abuse. Categories of abuse including financial exploitation, neglect and self-neglect are typically not used in IPV prevalence studies.
Another distinguishing factor with studies on IPV and older women is that the definition of perpetrator is restricted to current or former spouse, partner or dating partner, or stranger in the case of sexual abuse, including rape. Perpetrators with whom victims have a trusting relationship, such as adult children and grandchildren, neighbors, friends and both formal and informal caregivers, are not generally included in the perpetrator category for IPV research. Finally, the setting in which IPV is assumed to take place is the home or community, not a care facility or institution.
Sadly, some research guides for conducting IPV research include ageist directives. In a technical guide on producing statistics on violence against women promulgated by the United Nations Department of Economics and Social Affairs in 2013, readers are advised that “some countries have opted to set an upper age limit for respondents, the reasons being that older people are more prone to memory recall problems and tend to have a general reluctance to discuss sensitive subjects… It is also likely than an older age category will be too small to allow for separate analysis” (page 15). Misguided and misinformed statements like this discourage researchers from including older women in studies on violence against women, and seemingly encourage nations to exclude data on older women from domestic violence reports that inform national and international policy making (7).
All of these factors serve to minimize abuse of older women in studies of IPV and women of all ages, giving the impression that compared with younger women, older women experience insignificant amounts of abuse. This serves to discourage inclusion of older women, based on an assumption that the small number of older women experiencing IPV does not warrant the expense and effort of collecting data on this population or including these data, if collected, in the analysis, unless a research partner separately analyzes the data sub-set on older women (8).
Data sources for IPV research on older women include large scale government population, household, health, and criminal justice surveys using questionnaires and telephone interviews, with some face to face interviews, smaller scale health surveys using telephone and in-person interviews, and some agency surveys. Some of the more significant and accessible prevalence research on IPV that include women across the life course has been done in Finland, Canada, Albania, and the USA (9-16). A few smaller prevalence studies on elder abuse conducted in Hong Kong used CDC measures and disaggregated male and female data in the analysis, for example a Hong Kong study using subjects from senior community centers (17,18).
Prevalence research in the USA specifically on abuse of older women using some variation of the CDC definition has been undertaken utilizing samples of older women drawn from health care provider lists (19-21), or sub-samples from large scale studies on health care. While prevalence of IPV for older women is scant, some studies have begun to gather data on this. In one study conducted in the USA, past-five-year violence prevalence was 3.5% and past-year violence prevalence was 2.2% for a sample of women age 65 years and older (19).
In a study on IPV and German older women, prevalence rates for the past 12 months were reported as 2% for women aged 50-65 and 0% for women aged 66-86 for a combined 12 month prevalence rate of 1%. Physical or sexual violence, or both, for women age 50-65 was higher than for women age 66-86 whether it was reported in the past 12 months (2% compared to 0%), the past 5 years (3% compared to 1%) or in a current relationship (14% compared to 5%). These findings underscore the importance of examining cohort specific data for older women victims of neglect, abuse, and violence (22).

Older women and IPV from a life course perspective
Existing data also demonstrate that the problem of IPV and older women is significant, if viewed from a life course perspective. In the USA study, lifetime partner prevalence rate for women age 65 and above is 26.5%, with 18.4% women experiencing physical or sexual violence, and 21.9% experiencing non-physical abuse. In the study of German older women and abuse, the lifetime prevalence of physical and sexual partner violence is 23% among women 50-65, and 10% among women 66-86 years of age, for an overall lifetime prevalence rate of 18% for women age 50-86 years. According to the World Health Organization, based on WHO global and regional estimates of violence against women, estimated lifetime prevalence for IPV (physical, sexual and psychological abuse) among ever-partnered women in the 65-69 age group is 22.2% (23).

Prevalence research on older women, elder abuse and adult protection
Research on older adult abuse and adult protection is generally guided by a definitional set that was formalized by the US National Research Council (NRC) in 2003 (24). It assumes older adult victims are vulnerable (a central concept of this research paradigm), possibly cognitively compromised, physically impaired, and often frail as well.
Research on abuse prevalence with this population is difficult due to challenges of access, institutional review board requirements and informed consent, care dependency, and possible care home residence setting. In the USA, UK and Japan, established old age protective care systems have made elder abuse research on this population more viable, and more subjects are likely to be women, who tend to live longer with chronic impairments compared to men (25). Data sources for research on vulnerable older adults include agency records, secondary data sources, third party sources and surrogates including caregivers, and professionals in the fields of healthcare delivery and adult protective services.
Research using some variation of the NRC definition has been done primarily with care dependent older adults or those residing in institutional settings. One of the few studies done on abuse of older women using this definition was with geographically specific subjects on Adult Protective Services (APS) agency caseloads. APS agencies are located in all states in the USA, and serve adults, including older adults, who are unable to provided needed self-care due to mental or physical limitations, and have no one willing or able to assist them remain safely in their homes and communities. Examples include a study conducted with older rural and urban women living in the State of Illinois, USA, who were known to county APS offices or a sub-set of older women known to APS (26,27). The NRC definition of abuse includes vulnerable older adults, potentially eliminating older women victims who are not vulnerable or care dependent.
Because older adults in adult protective systems have some degree of health, mental health and/or cognitive impairment, subjects’ age in adult protective studies is likely to begin at 65 years, making prevalence comparisons difficult for studies where the old age is defined as 60 years or even as in IPV studies, younger than 60 years of age. The baseline health of these subjects is likely to be poorer overall than that of subjects in the IPV or social gerontology frames.
Large scale research studies specifically on incidence of abuse of older women have not been done in this research frame. However, one incidence study completed in the USA found that older adult women were abused at a higher rate than males, after accounting for their larger proportion in the aging population of the USA (29). Older adult victims for this study were selected from APS caseloads throughout USA, and were more likely to be impaired than subjects in a general population survey. Older women victims in this study were more likely to be over 80 years of age, and more likely to experience neglect or self-neglect (28).

Cultural factors in neglect, abuse and violence of older women
Existing prevalence data on older women and neglect, abuse and violence suggest that age cohort and cultural factors can influence findings. However, differences between prevalence studies in Eastern as compared with Western studies are less that might be thought. Data are limited for older women and abuse in Asian cultures due to cultural reticence and definitional issues, according to Shibusawa & Yick (29), but recent studies on elder abuse of older women and men conducted in Hong Kong, Mainland China, Taiwan, South Korea and South Asia are beginning to increase understanding of abuse by gender and age of victims in Asian countries (30,31).
In a Hong Kong study on elder abuse by caregivers of community dwelling older adult members of community centers for the elderly, 28% of older women subjects reported experiencing verbal abuse, 6% reported experiencing physical abuse and 29% reported experiencing violation of personal rights (32). In a study on intimate partner violence among community dwelling older adult couples living in Hong Kong, past 12 month abuse rates by form of abuse reported by older female subjects were: 1.37% physical abuse, .8% sexual abuse, and 33.7% psychological abuse (17). In the same study, lifetime physical abuse prevalence rate was reported at 6.2% by older women age 60 years and above, 3.5% lifetime sexual abuse, and 50.6% lifetime psychological abuse rate. This study used the Conflict Tactics 2 Scale to measure partner violence and findings are comparable to western studies of intimate partner abuse among older women.
A prevalence study of elder abuse was conducted in The People’s Republic of China among community dwelling older adults living in a rural community age 60 years and older. Subjects included both older men and older women (33). The study found that 6.3% of the sample of older women reported experiencing physical abuse, 28.4% reported experiencing psychological abuse, 13.8% reported neglect, and 1.9% reported financial abuse.

Comparison of data collection methods for different research frames
Data collection methods to obtain prevalence rates of neglect, abuse and violence against older women are complex, expensive and time consuming. In population studies, computerized modeling, random sampling, instrument development including language translations, interviewing strategies, protection of human subjects protocols, and use of secondary data and third party information sources are all daunting challenges. Large scale multi-national studies also require coordinated research teams to ensure reliability and validity of collected data.
In research using the adult protective frame, use of hospital, law enforcement, or agency records and provider input may be necessary for collecting data on institutionalized or cognitively impaired older adults, but this can result in poor quality data and compromised findings. Records may be confidential and only available in statistical reports, making cross-referencing with other agency data or longitudinal comparisons impossible except through sophisticated statistical modeling strategies. This presents a challenge even for developed countries, much less for developing countries and those under development.

Comparison of findings from different research frames
There has been considerable debate among proponents of these different research frames as to which is most salient for understanding prevalence of elder abuse. While proponents of the adult protection frame suggest that much has been learned and continues to be learned about elder abuse research from child protection (34), proponents for the IPV frame suggest prevalence studies in elder abuse do not fully consider IPV in later life. According to some leading experts in social gerontology research, the field of elder abuse and mistreatment is “casting off positions embedded in other areas, such as child abuse and domestic violence…” (35). They suggest that if researchers hold to an assumption that older adult victims with diminished capacity or other impairments no longer have the ability or right to exercise self-determination and autonomy, or that abuse and neglect always reflects a power and control relationship between abuser and victim, their ability to generate heuristic findings may be compromised.
Using the IPV frame, a different profile of abused older women emerges in contrast with the profile that emerges from the social gerontology or adult protection frames. In the IPV frame, using a limited number of measures related to abuse and perpetrator, older women are significantly less likely to experience abuse than younger women; however, in the social gerontology frame older women are found to experience significant rates of abuse.
While the overall abuse rate found in prevalence studies in the social gerontology frame is higher than prevalence rates for older women found in IPV studies on women of all ages, the physical abuse rate for older women in studies using the social gerontology frame is comparable to findings of physical abuse rates for older women age 60 and above in these studies. The use of the CTS2 in the DAPHNE III studies of older women to measure physical abuse (36) makes this rate more comparable to IPV studies where the CTS2 is generally used to measure physical violence of women of all ages.
Incidence studies in the adult protection frame have not to date focused exclusively on older women, but they have highlighted those forms of abuse, specifically neglect and financial exploitation, that most affect women age 80 and above. A small number of studies highlight sexual abuse of older women in protective settings (37,38); however, these typically do not include prevalence data.
This overview of the prevalence of neglect, abuse and violence against older women based on different and sometimes competing research frames demonstrates the difficulties in using these data to understand and promote older women’s right to live lives of dignity, free of abuse. In order to address the current fragmentation in research on older women and neglect, abuse and violence, the international research community must come together to formulate guidelines that standardize measures, eliminate ageist views, and reflect a more holistic perspective on older women in society.
In her third and final article, Dr. Brownell will present preventive strategies as well as interventions to address neglect, abuse and violence against women, using the three research frames she has identified in this article.

Acknowledgement
Dr. Patricia Brownell served as consultant to the United Nations (UN) Department of Economic and Social Affairs (DESA) in drafting a paper on neglect, abuse and violence against older women. In November 2013, the UN DESA held an Expert Group Meeting (EGM) inviting researchers and other experts from around the world to New York City to review the state of knowledge, gaps, and next steps to address this area of human rights violations against older women.

Conflicts of interest: None declared.

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