Elderly Abuse and Neglect on Population Health: Literature Review and Interventions from Selected Countries

1. Study Design and Samples

We used a literature review design and searched PubMed (https://pubmed.ncbi.nlm.nih.gov/), Scopus (https://www.scopus.com/ home.uri), and Springer Link (https://link.springer.com/advancedsearch) for materials written solely in English from the beginning of database records until December 15, 2022. Both “elder abuse” and “neglect” were used as search phrases. No restrictions were placed on the samples, and only studies or reports on elder abuse and neglect were included. To find pertinent research for incorporation into the analyses, we searched the references of the chosen publications. Because this was a narrative review, no attempt was made to find unpublished studies or literature in other languages, contact researchers to obtain unpublished data, or conduct a meta-analysis.

This study was not subject to ethical approval. However, we adhered to the ethical standards outlined in the 2008 version of the Declaration of Helsinki published by the World Medical Association (https://www.wma.net/wp-content/uploads/2018/07/DoH-Oct2008.pdf).

2. Study Variables

The primary outcome variables were the concept of aging, prevalence of elderly abuse and neglect, risk factors, effects, measures or interventions by country, and legal perspectives.

1. Concept of Aging

Those over the age of 60 are referred to as elderly or senior citizens, a term accepted by the United Nations World Assembly [4] on Aging in Vienna and by the ASEAN (Association of Southeast Asian Nations) nations, including Malaysia. According to science, aging is the outcome of a variety of molecular and cellular damage that accumulates over time. As a result of the natural aging process, physical and mental capacity gradually deteriorates, disease risk increases, and mortality eventually occurs. The diversity observed as people age is not random; these changes are neither linear nor consistent [4]. Hearing loss, cataracts, refractive errors, back and neck discomfort, osteoarthritis, chronic obstructive pulmonary disease, diabetes, depression, and dementia are some of the most prevalent health disorders affecting older adults. Individuals are more likely to experience multiple ailments concurrently with age. The rise in various complicated medical problems, known as geriatric syndromes, is another feature of older age. Examples include frailty, urinary incontinence, falls, delirium, and pressure ulcers, all of which frequently result from several underlying causes [4]. Moving away from biological subjects, aging is frequently linked to other life transitions, such as retiring, moving to a more suitable home, and losing friends and companions.

2. The Phenomenon of Global Aging

The rapid rise in the total and relative numbers of older people worldwide, which is a result of two public health initiatives—longer life expectancies and lower fertility rates—is an indication of the global aging phenomenon. Between 2015 and 2050, there will be 56% growth projection of people worldwide aged 60 years or older, representing an increase from 901 million to more than 1.4 billion, which will accounting for 22% of the world’s population [5]. As a result of this demographic transition, social services, healthcare, and financial, legal, and political systems will all face new challenges in the 21st century and become top priorities for governments.

3. Demographic Transition in Malaysia

Similar to other emerging nations, Malaysia’s older population is expanding quickly relative to younger age groups. In 1991, 5.8% of Malaysia’s overall population (approximately 1 million older adults) was thought to belong to this group. Due to a sharp fall in fertility rates and an increase in life expectancy, this percentage is predicted to double to 10.7% (3.5 million older persons) by 2020 and reach approximately 15.3% by 2030. In accordance with present and future demands, the Malaysian government adopted the National Senior Citizens Policy and National Senior Citizens Action Plan on January 5, 2011 [6]. By maximizing individuals’ potential through healthy, positive, active, productive aging, the government is committed to improving citizens’ quality of life and the nation, recognizing the need for independent, dignified, senior citizens in both documents [7].

The idea of older persons’ well-being became the center of all actions and choices in both policies. The five dimensions of aging are as follows [7]: (1) Healthy aging: encompasses efforts to lead a healthy lifestyle, improve the healthcare system, and develop surroundings and communities that promote health. (2) Positive aging: the practice of having beliefs and ideals that serve as the foundation for senior individuals’ identities and ways of life, as well as positive attitudes and viewpoints toward aging. (3) Active aging: the process of maximizing senior citizens’ participation in family and community activities to enhance their well-being. Relevant factors include the quantity, quality, and scope of social networks, as well as reciprocal roles and long-lasting interactions between generations. (4) Productive aging: this concept describes citizens’ ability to participate in paid work activities or volunteering that can provide a sense of purpose and happiness. (5) Aging support: includes senior-friendly interiors and exteriors that make it easier for seniors to function, decrease the number of people with disabilities, and provide a supportive atmosphere for promoting senior participation in the community. This component considers how technology can be used to support citizen independence.

In sum, the policy framework states that well-being includes the facets of health (healthy aging), social (active aging), economic (productive aging), spirituality (positive aging), and environment (supporting aging). Seniors who can achieve an equilibrium across all five dimensions will have fruitful lives.

4. Definitions of Elderly Abuse and Neglect

Scholars have provided numerous definitions for elder abuse and neglect. The earliest definition was provided by O’Malley et al. [8] in 1979, who stated that it included “the willful infliction of physical pain, injury, or debilitating mental anguish, as well as the unreasonable confinement of or deprivation of services by a caretaker which are necessary to the maintenance of mental and physical health.” In 1984, Eastman [9] described elder abuse as systematic mistreatment (physical, emotional, or financial) of elderly person by caring relative. Additionally, senior neglect is a specific form of elder abuse in which an elderly person is unable to care for themselves or not receiving the care required to maintain their physical and mental health.

5. Types of Elderly Abuse

The Centers for Disease Control and Prevention (CDC) divides elder abuse into five major categories, as listed below [10]: (1) Physical abuse: characterized by the intentional use of physical force including beating, kicking, pushing, slapping, and burning, that cause an elderly person to experience disease, suffering, injury, functional impairment, distress, or death. (2) Sexual abuse: coerced or unwelcome behavior involving sexual contact with an older adult; can involve unwelcome attempted or completed sexual contact or penetration or even noncontact behaviors such as verbal harassment. (3) Emotional or psychological abuse: includes verbal or non-verbal acts that cause older adults to feel sadness, mental anguish, fear, or discomfort. Examples include embarrassment or disrespect, verbal and non-verbal threats, harassment, and social or geographical isolation. (4) Neglect: defined as the inability to provide the fundamental requirements an elderly person needs (e.g., food, water, shelter, clothing, hygiene, and necessary medical treatment), it is regarded as a form of elder abuse. (5) Financial abuse: the illegal, unauthorized, or improper use of an elder’s funds, benefits, possessions, property, or assets for the benefit of someone other than an older adult.

6. Causes of Elderly Abuse and Neglect

It was once thought that the factors contributing to elder abuse and neglect in emerging nations were the effects of rapid demographic change, widespread urbanization, and Westernization, all of which have transformed the local social structure, societal norms, and traditional values. One of the developments that may be observed is the contribution of women to family income generation, as opposed to their traditional role as primary caretakers in their homes or even caregivers for elderly parents [11]. Research has shown that the erosion of ties and social interactions with the elderly is the result of economic growth and industrialization.

In addition, the tendency of young people to move from rural to urban areas in search of better employment or educational possibilities frequently causes older people to feel excluded and to lose their support systems [11]. While Asian nations continue to maintain a strong culture of filial piety, many ancient conventions and values—especially those pertaining to family connections—have been affected as they move along the path of contemporary development.

7. Theoretical Approaches to Understanding Elderly Abuse and Neglect

However, because determining the precise reasons for elder abuse and neglect is a complicated and multifaceted topic, their occurrence cannot be fully explained. Figure 1 summarizes the theoretical frameworks for comprehending elder abuse and neglect [12].

Figure. 1.

Summary of theoretical approaches to understand elderly abuse and neglect. Adapted from Burnight K, Mosqueda L. Theoretical model development in elder mistreatment [Internet]. Washington (DC): U.S. Department of Justice, Office of Justice Programs; 2011 [cited 2023 May 10]. Available from: https://www.ojp.gov/pdffiles1/nij/grants/234488.pdf [12]

The caregiver stress hypothesis, first put forward by Wolf [13] in 2000, asserts that elderly abuse and neglect are the result of carer burnout or tiredness brought on by having to continuously care for a dependent and impaired victim. Another idea was the social learning theory, sometimes known as the cycle of violence theory, developed by Bandura [14] in 1978 based on their work on child abuse. According to this theory, abuse is a learned behavior that is passed down from one generation to the next. The results showed an individual who watches or suffered abuse as a child is more likely to abuse other members of their family as adults, including their elderly parents. On the other hand, the social exchange theory, developed by Homans [15] in 1958, focuses on the disparity of power and involvement in the dynamics of the interaction between the victim and offender. Later, in 1990, Walker [16] proposed a nearly identical theory known as the power and control theory, which emphasizes the abuser’s coercive techniques for gaining and maintaining power and control in the relationship. The dyadic discord theory by Riggs and O’Leary [17] states that family violence frequently results from dysfunctional relationships and actions. Moreover, ecological theory introduces the idea that people are part of a network of interactive environmental systems that affect how they develop personally and perceive life [16]. The components under environmental system are macrosystem (such as age, gender disparity, and aggressive societal standards); exosystem (such as economy and community integration); microsystem (such as individual and family traits); and ontogenetic subsystems (including physiology, affect and behaviour) [18].

The most recent theory is the contextual theory of elder abuse proposed by Roberto and Teaster [19], which is based on two models: the CDC’s social-ecology model and Bronfenbrenner’s ecological model. Specifically, this theory acknowledges the intersectionality of individual identities, the dynamic relationships of older people, the impact of individual characteristics on elder abuse incidents, how those incidents relate to the lives of others, how communities respond to older adults, and the strength and influence of societal norms and values in promoting or discouraging elder abuse [16].

8. Prevalence and Risk Factors of Elderly Abuse and Neglect

Many studies have addressed the global problems of elderly abuse and neglect. However, the prevalence has been overstated owing to various definitions and interpretations of elder abuse and neglect depending on the context. Table 1 provides a few illustrations of earlier research and key risk factors identified [1,20-29].

Table 1.

Summary of literature reviews on global elderly abuse and neglect

9. Consequences of Elderly Abuse and Neglect

Many studies have documented the vast range of negative impacts of elder abuse and neglect on victims’ health and well-being. However, there are only a few available sources. Premature mortality, sadness, and anxiety are some of the health effects mentioned. Moreover, there were reported suicidal thoughts, digestive problems, and high hospitalization rates involving elderly population [26]. These seniors may experience various physical and psychological repercussions of abuse and neglect. Psychologically, victims typically develop fears and anxieties and struggle to trust others. Minor cuts, scratches, bruises, and welts are the most common types of wounds. More severe injuries, including head trauma, shattered bones, ongoing bodily pain, and soreness, can result in long-term impairment. Physical harm can worsen pre-existing medical conditions and result in early mortality [10].

In other meaning, elder abuse and neglect do affect physical health, mental and psychological health, and healthcare utilization. In term of physical health can be from premature mortality, musculoskeletal pain or chronic pain, poor general health, gut symptoms, incontinence, decline of physical function and life quality, metabolic syndrome, diabetes, weight problem, headache, allergy, somatic complaints and disability. While for mental health, abuse can cause depression, poor mental health, psychological distress, anxiety, suicidal thoughts/attempt, stress, sleeping problem, social dysfunction and poor self-rated health. Lastly, the elder abuse and neglect indirectly will cause increment healthcare utilization through rising visits, hospital admissions, resources used and also nursing home admissions [30].

10. Interventions or Approaches to Combat Elderly Abuse and Neglect in Malaysia

From a legal perspective, a number of laws offer protection to senior citizens. The Domestic Violence Act (DVA) of 1994, the Criminal Code, the Care Center Act of 1993, the Employment Act of 1955, the Pensions Act of 1980, and the Workers Provident Fund Act of 1991 are a few examples of civil law measures that fall within this category. While as Malaysia is a Muslim country, there is also the Islamic Family Law Act of 1984 that governed by Shariah law of the country which also affords certain protection to older adults [31].

Aside from the application of the aforementioned laws, there is no other direct action or plan for dealing with elderly abuse and neglect in Malaysia. However, some Malaysian laws afford a degree of social protection to the elderly under the National Policies on Aging, which is engaged in inter-ministerial cooperation. An example of such laws is the National Policy for Older Persons (2011), coordinated with the National Health Policy for Older Persons (2008) by the Ministry of Health. With the provision of senior-friendly services and conducive surroundings, these policies place a strong emphasis on empowering individuals, families, and communities to enhance their well-being, care, and protection in old age. The Department of Social Welfare (for social and recreational activities), the Ministry of Education (for academics and spirituality), the Ministry of Housing and Local Government (for housing and the environment), the Economic Planning Unit (for the economy), the Ministry of Human Resources (for senior employment), and the Ministry of Science, Technology, and Innovation (for research and development) also have technical committees involved in supporting older adults [5,32].

The Gerontology Institute was founded on April 1, 2002. In 2015, it was upgraded to a national-level institution and renamed the Malaysian Research Institute of Aging (MyAging). Employing a multidisciplinary approach, this institute constructed a body of research on the elderly and aging in Malaysia. Likewise, the findings of the current study will be made available to the public through scholarly papers, seminars, and media releases. To increase the role of institutes in the subject of aging, this institute also develops partnerships and broadens networks with governmental organizations, the corporate sector, non-governmental organizations, and other agencies at the national and international levels. In addition to offering postgraduate degrees in the fields of medical, social, and gerontechnological aging, the integrated complex provides a range of amenities that support active and productive aging [33]. There is no explicit policy against elder abuse or neglect in Malaysia other than the previously specified behaviors. Nonetheless, a focused research initiative called the PEACE (Prevent Elder Abuse and Neglect Initiative) is still ongoing at the University of Malaya [34].

11. Interventions or Approaches to Combat Elderly Abuse and Neglect in Other Countries

12. COVID-19’s Impact on Elderly Abuse and Neglect

It is important to draw attention to the fact that the coronavirus disease 2019 (COVID-19) pandemic has had a disproportionately negative impact on elderly citizens and older individuals. In addition to dying more frequently due to COVID-19 infection, they also experience abuse and violence at home and in institutions. It is clear that the victimization of older age groups has received less attention than intimate relationship violence and child abuse.

The financial, monetary, and social welfare sectors are experiencing significant stress as a result of the COVID-19 pandemic. Inadequate attention has been paid to the precarious circumstances of vulnerable groups such as at-risk older populations in institutions and communities, particularly elderly people living alone. The exclusion of care centers from the definition of an essential service under Malaysia’s Prevention and Control of Infectious Diseases Regulations 2020, which impacted the operations of old people’s homes, mental health facilities, and orphanage homes, is a typical example of the beginning of a Movement Control Order (MCO). Several organizations can provide relief and assistance to the poor by following standard operating procedures thanks to the clarity they provide.

There is also a pressing need to consider the numerous challenges that elderly people encounter when trying to obtain food and other necessities during lockdowns, including replenishing medication and receiving other standard medical services such as wound care, dialysis, or rehabilitation treatments. We must keep in mind that many seniors are illiterate, in a financially precarious condition, and less technology-savvy than ordinary people. It has been challenging, especially without younger family members present, to manage various transactions online or through self-service kiosks after offices and workplaces are closed (as their children might also be restricted from entering their homes). According to this theory, alternatives must be created for population segments with lower levels of Internet access, and lockdown measures must address the concerns of marginalized groups, including the underprivileged and people with disabilities. Likewise, it is important to pay sufficient attention to the livelihoods of daily gamblers, petty traders, laborers, agricultural and fishery workers, and many others working in unorganized sectors. Although MCO may only be a minor inconvenience to some, it may be essential for others’ survival. The strain on family caregivers must also be considered when caring for elderly patients with various morbidities in such a unique and unsettling setting.

Thus, by enhancing disease identification, prevention, response, and control in older people living in institutions and communities, all parties should actively contribute to the capacity of the aged care sector to reduce the negative effects of COVID-19. For the duration of the outbreak and beyond, we must work together to implement evidence-based, cogent health and social care measures that strike a suitable balance between the rights of older adults and potential hazards. Multidisciplinary experts in gerontology and geriatrics should be consulted as needed to put knowledge into practice and to discuss plans for the future of aging and society in the post-COVID-19 period.

13. Public Health Applications and Implications

This article demonstrates the gravity of elder abuse and neglect and emphasizes the substantial action that should be taken to address it. Coordinated efforts involve numerous community organizations such as hotlines, shelters for the homeless and victims, emergency funds, and support groups. To analyze and evaluate elder abuse cases and prepare integrated and holistic support for these victims, stakeholders from the main service bodies should convene regularly, ideally once a month. Stakeholders may include experts in APS, case management, family counselling, geriatrics, mental health, and civil and criminal laws. Meanwhile, promising interventions for carers include help in the form of support groups, counselling, homemaking aid, volunteer buddies/advocates, and training in caregiving.

Rules might vary according to their goals, which can serve as protection for victims and survivors or even as a preventative measure before an incident happens. Following a review of an earlier version of the policy from 1995, Malaysia’s National Policy for Older Persons (2011) was created with the goal of empowering individuals, families, and communities to provide age-friendly services for older people in an effective and efficient manner and to ensure supportive environments for their well-being.

Laws or legislation is undoubtedly another method of prevention since it enacts measures to hold perpetrators accountable, deters future offenses, and shields victims from further harm. As previously explained, there are several legal measures in Malaysia, including the Criminal Code and the DVA 1994. Nonetheless, concerns have been raised about the efficiency of these current laws in combatting elder abuse and neglect because they are thought to be insufficient, vague, and not entirely compatible with the nature of such incidents.

It is crucial to remember that in cases of abuse and family violence, the legal route is not always the best or most effective treatment. Researchers and other stakeholders must be extremely sensitive to the cultural settings, norms, and values of a particular society to determine what is best for a particular victim.

14. The Way Forward

In Malaysia, and throughout the world, several measures need to be implemented to prevent elder abuse and neglect. First, it is crucial to raise awareness of elder abuse and rights among all age groups, including younger generations, working-class people, and school children. Second, we must teach all healthcare professionals and caregivers elder how to identify abuse and handle suspected cases. Third, we need to provide clear, evidence-based criteria for the identification of elder abuse and neglect as well as a referral process. Fourth, a specific legislative requirement, such as the New Elder Act, must be enforced. Fifth, we ought to offer rewards (e.g., tax breaks) as incentives for helping or caring for the elderly. We have tax benefits that are solely available to parents and indirectly related to older people in Malaysia, such as RM 8,000 in rebates for medical care, special needs, and care costs. Sixth, to attract working groups, we need to broaden our focus to implement interventions aimed at avoiding elder abuse and reducing neglect by meeting older adults’ basic needs. Seventh, considering contemporary technological advancements, we need to inform seniors about cyber risks. Elderly people are more likely to be targeted to provide personally identifiable information or make financial contributions to people posing as someone they know as they use technology for entertainment and communication with loved ones, especially when visits from family and friends are restricted. Accordingly, education is the key to preventing regrettable cyberattacks or fraud in older people.