An Exploration of the Knowledge and Current Practices of Frontline Workers Regarding Elder Abuse

Abstract

Annually, approximately 16% of adults aged 60 and older are victims of abuse in community settings. A critical first step toward effectively intervening and reducing the prevalence of elder abuse is to better understand the current state of knowledge, beliefs, and practices. This qualitative descriptive study explored the perceptions of US frontline community workers regarding elder abuse through focus groups and interviews conducted in the spring and summer of 2021. Participants represented various aging and victim services (n = 9), healthcare (n = 7), and law enforcement (n = 8). Thematic data analysis led to the emergence of three major themes in our data: societal influence, individual circumstances, and nature of abuse. Our findings point out several directions in which researchers and policymakers can begin moving the field forward. These include the need to focus on prevention strategies as well as the need to reduce ageist beliefs and attitudes.

Keywords

abuse and neglect ageism qualitative methods financial abuse

What this paper adds

• A deeper understanding of the current landscape surrounding abuse of older adults in community settings.

• Evidence of ageism at multiple levels that inhibits effective response and prevention of elder abuse.

Applications of study findings

• Findings strongly point to the need to address ageism as an elder abuse prevention strategy.

• Findings align with and support the World Health Organization’s recommendation to align policies and systems to optimize greater health and well-being for older adults.

Elder abuse is any intentional or negligent act that harms or increases risk of harm to older adults (National Center for Injury Prevention and Control, 2021), often committed by trusted individuals (U.S. Centers for Disease Control and Prevention, 2024). There are many forms of elder abuse, including physical, sexual, psychological, financial, neglect, and self-neglect (U.S. Centers for Disease Control and Prevention, 2024). Multiple forms of abuse can simultaneously co-occur (U.S. Centers for Disease Control and Prevention, 2024). Pre-pandemic, about 16% of older adults globally experienced abuse annually (Yon et al., 2017), rising to 21% annually post-pandemic (Chang & Levy, 2021). For each known case of elder abuse, as many as 24 cases are never reported (Lachs & Berman, 2011). Older adults who have experienced abuse are at risk of premature mortality (Yunus et al., 2019), multi-morbidity (Yunus et al., 2019), anxiety and depression (Acierno et al., 2017; Wong & Waite, 2017), poor functional health (Wong & Waite, 2017), hospitalization (Dong & Simon, 2013), feeling a sense of loneliness (Wong & Waite, 2017), and being placed in a long-term care facility (Lachs et al., 2002). Early recognition and effective response play key roles in reducing the occurrence and impact of elder abuse.

Research indicates that healthcare workers lack confidence and competence in recognizing elder abuse across various clinical settings (Braaten & Malmedal, 2017; Daly & Coffey, 2010; Gonzalez et al., 2016; Rosen et al., 2016, 2018). Contributing factors include lack of training (Gonzalez et al., 2016; Rosen et al., 2018) and insufficient knowledge of elder abuse (Braaten & Malmedal, 2017; Daly & Coffey, 2010; Rosen et al., 2016, 2018), as well as challenges to reporting elder abuse (Gonzalez et al., 2016). For example, a recent qualitative study revealed that radiologists reported having very little or no training in elder abuse detection and that these professionals never reported a suspected case despite believing they had encountered elder abuse (Rosen et al., 2016). Similarly, a sample of emergency department providers reported not routinely assessing for elder abuse (Rosen et al., 2018). These same providers reported overlooking abuse for various reasons, including a poor understanding of what constitutes elder abuse, inadequate training, challenges in distinguishing between mistreatment and standard age-related functional status, distrust of histories provided by older patients, and an absence of clear protocols to follow when elder abuse is suspected (Rosen et al., 2018).

As the world’s population ages, elder abuse is expected to rise (World Health Organization, 2022), posing significant costs and challenges despite decades of warning. Prioritizing the safety of older adults is a global priority, as highlighted by the United Nations’ call for re-evaluation and realignment of policies and programs to optimize quality of life and safety (United Nations Department of Economic and Social Affairs, Population Division, 2022). Unlike much of the research on elder abuse, our study delved into elder abuse in community-based settings to shed light on how various frontline workers respond to elder abuse individually and collaboratively. Thus, we conducted a qualitative descriptive study to answer the following research question: what is the current knowledge of abuse and beliefs about current practices and effectiveness of recognition and response, among central Virginia’s frontline community workforce?

Methods

Participants

Participants (n = 25) working with older adults in various settings were recruited through purposive sampling to take part in either a semi-structured focus group. Representatives from aging and victim services (n = 9), healthcare (n = 7), and law enforcement (n = 9) who worked in central Virginia in either an urban (n = 13), suburban (n = 9), or rural setting (n = 3) participated in this study. There was no prior acquaintance between study participants.

Procedures

All study procedures were approved by the Institutional Review Board of the researchers’ university (IRB Protocol: HM20020135). Participants were recruited online; electronic fliers were distributed through email listservs and advertised on social media. The three fields targeted for recruitment in the study—aging and victim services, law enforcement, and healthcare—were chosen because they are commonly included as members of multidisciplinary teams (MDTs) and are well-poised to interact with and recognize elder abuse in community settings. Interested participants contacted the project manager, who coordinated the scheduling of focus groups and interviews. The project manager then gave interested participants an information sheet detailing the purpose of the study as well as gathered informed consent from participants before adding them to the schedule of focus groups. Participants did not receive compensation for participating in the study. Five focus groups took place with three to five participants present. Two focus groups were scheduled to have three or more participants present but only one participant was able to attend. Three other participants were the only ones to sign up for their focus group timeslot; they were not available to join larger focus group sessions but were eager to participate. These five individuals were all interviewed one-on-one using the same semi-structured protocol.

All focus groups and interviews were conducted in the spring and summer of 2021 by the same researcher (AR) to ensure consistency across conversations. The questions began by asking participants to broadly consider and define what it means to be old and to be abused before moving specifically toward questions regarding their discipline’s role in response to abuse and what they believe other disciplines’ role is. Participants were also asked to comment on their experiences collaborating with other disciplines to respond to elder abuse. The full semi-structured protocol is in Appendix A. Given that we asked participants to discuss their experiences and perspectives in other disciplines, disciplines were not mixed during focus groups to ensure participants felt comfortable speaking openly about their experiences. All focus groups and interviews took place on teleconferencing software and were recorded; conversations ranged in length from 30 to 75 min. Audio-only recordings were sent to a third-party service for transcription.

Data Analysis

Transcripts were imported into Excel for data analysis. Three research team members (SM, MY, and DP) reviewed all transcripts, making notes about topics and ideas represented in the data. After independent review of all data, the group collaboratively developed the codebook. Initially, the codebook consisted of 75 descriptive codes developed using open, inductive coding (Saldaña, 2016). After creating the codebook, the three researchers independently coded three transcripts and then came back together to compare code usage. This ensured that each researcher was using and interpreting codes similarly; four codes were added to the codebook during this meeting. Once all team members were confident in their use and understanding of the codes, all transcripts were then coded independently by two researchers (MY and DP), including the three coded during codebook development; all discrepancies were settled by a third reviewer (SM) to consensus. Using thematic analysis (Braun & Clarke, 2006), similar codes were grouped into categories to understand patterns within responses; these categories were then grouped into themes to make sense of the data (see Tables 1 through 3). For example, the following codes were grouped into the sub-category “knowledge of abuse”: training/education, difficulty recognizing elder abuse, signs of abuse, and knowledge. Final themes were discussed with the entire research team to ensure themes were representative of the data.

Table 1.

Sub-Categories, Codes, and Exemplar Quotes for the Societal Influences Theme.

Sub-Categories	Codes	Exemplar Quotes
Knowledge of Abuse	Training/education	We’re trained so much on child abuse, sexual abuse, domestic abuse, but elder abuse really isn’t touched on unless you work specifically in an area like special victims or something like that. -law enforcement participant
	Difficulty recognizing elder abuse	I think there should be something out there…so they can recognize the different forms of abuse, because some elderly people may not think of certain abuses the way we see it as it being abuse… -aging and victim service participant
	Signs of abuse	I would classify abuse as somebody is knowingly and deliberately taking advantage of you, whether that is emotional, financial, or physical. That can be anything from physical violence, deliberate emotional trauma, or financial exploitation. -law enforcement participant
	Knowledge	…everyone’s carrying a caseload that doesn’t always fit their knowledge base. -health care participant
Addressing Abuse	Legality	I don’t find the legal system helps too much. Like, declaring someone incompetent doesn’t always get you a whole lot. -health care participant
	React vs prevent	But law enforcement by its definition is a reactionary entity. We respond when something has happened. Legally, we have almost no authority to take any action before an event occurs, so the issue of prevention, while essential, is kind of tricky. -law enforcement participant
	Reporting	There’s no reporting like for kids…For adults, they are kind of pushed to the side, almost, in society, so they’ll have one caretaker, and it’s usually a family friend or a family member. But if that family member is the abuser…so if they don’t report it because they’re the ones doing it, then it doesn’t ever get reported. -law enforcement participant
	Care coordination	It’s usually a team decision…what’s ultimately our goal, and can we achieve it by declaring incompetence and calling APS? Like, is that going to get us to where this person really needs to be? That’s not done is isolation. Very rarely do we make that decision alone. -health care participant
	Resources	I think designing and creating more friendly, accessible environments for people that are aging, either in place or in a nursing home, would be necessary for the future. -health care participant
	Support	I do see a lot of fierce independence, and it’s a tough balance, because you want to support people’s fierce independence—that’s actually a major component of our own American culture—so you want to do that, while giving them some support, and helping them to recognize that maybe there are some behaviors that they’re doing that are putting them at risk. -health care participant
	Case management	If I think there’s a medical issue, or a mental health issue, at least in my jurisdiction we have a very productive working relationship with our county’s mental health agency, so it’s pretty easy for me to pick up the phone and at least let them know, or say hey, this person needs services. -law enforcement participant
	Information sharing	Just based on supervisory issues and individual institutional motivations, it can be somewhat challenging to truly have full information. -law enforcement participant
	Jurisdiction	As you know, some jurisdictions do better than others…Sometimes they’re very helpful, and sometimes you have to make your dismay known so that maybe the worker needs to be changed to be more proactive for the client. -aging and victim service participant
	Advocacy	we’re going to take the appropriate action, whether it’s a guardian, whether it’s a financial conservator, or whether it’s to try to intervene with social services—whatever has to be done, as unpleasant as it may be at the outset. -law enforcement participant
	Confidential/safe space	to give them, one, a safe and secure place to live and then, two, a confidential way to express what they need to, to feel better and not fall into an anger pattern or a different way of expressing their grief. -health care participant
	Person-centered care	That goes back to if somebody is nonverbal and non-communicative, but an awareness generally for people to understand that even though they can’t talk, they can still, in certain cases, understand everything that’s going on around them. -health care participant
Perceptions of Resources and Supports	External helplessness	the rules are always changing; the rules never seem to stay the same, and so it’s really hard to help people when the rules keep changing and I can’t stay up on them, so that’s frustrating. Probably, like every new administration we get; I guess they’re all into something new. It would just be nice, I think, if there were some societal, structural appreciation for aging, but a lot of the policies seem to be made by the generation before that hasn’t gotten to aging. -health care participant
	Internal helplessness	I don’t really feel equipped to know what to do about it, because there are so many family politics and dynamics, but I definitely know it’s happening. -health care participant
	Not a societal priority	It’s like we’re not taking care of the elders that have put so much into our society, that actually created the foundation for us younger individuals to be living off of, and we just let them fend for themselves. -health care participant
	Overloaded system	The volume we deal with is always a problem with social services. Everybody needs more manpower. In a perfect world, if everybody was fully staffed, things would work better. -law enforcement participant
	Community support	Unless you need to bring a legal system in to help, what you really need is a committed individual, a family member or someone that’s trusted, that can help them transition to a safer place. -health care participant
	Politics	Yeah, and this is a very political time, and I won’t get into politics, but there’s a lot of money wasted…that could be going to the elderly, but that’s a whole other thing. That’s heartbreaking. -health care participant
	Disproportionate allocation	That’s what our prevention funding is for, for children. -health care participant
Beliefs about aging	Ageism	My grandmother is 85, and she is very active and young. She does not act like an 85-year-old woman -aging and victim service participant
	Internalized ageism	Hmm, well with the cold weather, my aches and pains in my joints have a different definition, maybe, than it used to -law enforcement participant
	Wisdom	And in other cultures, they really shelter those elders because the elders have the wisdom. They have a lot of wisdom. They know a lot of things that could benefit us. -aging and victim service participant
	Life experience	I really liked what [Name] said about it being a state of mind. I don’t think you can label ‘old.’ I do think that people get wiser as they age and more experienced, and I’m hoping that through this work we can recognize that about individuals. That’s it. -aging and victim service participant
	Generativity	…but just being in it together. I’m not taking care of you; I’m just helping you with this and in return you’re giving me this advice or having this discussion, something like that, just to have that sense of equality. -health care participant
	Stereotypes	I think that a lot of people just assume that older adults are vulnerable, and so that is the beginning of it, to recognize that this person is vulnerable and so now ‘let me see how I can exploit them or what kind of abuse I can inflict on them -aging and victim service participant
	Stagnant	But then there’s also the sedentary type that people see that just sit home, and they putter around the house, or they do their volunteer work, if they’re into that. And some just see, as you get older, the older people just do what they want. And there are so many vital people out there that take classes, that go on trips (not that anybody could go on trips right now) and engage with society. But a lot of the younger people – younger, I’m saying 20s, maybe into the 30s, not too much – think you just dwindle away. You shrivel up and go away. Whereas the other ones that have good relationships maybe with their grandparents or other neighbors that are active look at it differently. So it’s hard to say. -aging and victim service participant
	Reflective	…they’re considering how to move from the primary productive phase of their life…into a more reflective phase where your primary objective is not to grow your family, or grow your wealth or productivity, but it’s to reflect on what you’ve accomplished, perhaps. -law enforcement participant
	Aging/being old is individual	I think what it means is individual to the person, so especially the people I care for, I try to determine what it means to them, because it has a lot to do with how they perceive their own health and what they see as expectations for aging, and wellness, and sometimes disease and what their expectations around those diseases are. -health care participant
	Aging is a constant process	I also think as I’ve gotten older my perceptions of what it is to be older or aged or senior has changed, just because I think that line of demarcation has changed in our lives. 50 years ago, a 50-year-old was something completely different than a 50- or 60-year-old is now, as longevity has increased, as medical technology has increased. I think that line, as we say in the physical fitness world, that line of decrepitude that people reach I think has been pushed back for a lot of people. I honestly think my perception has changed over the years as I’ve gotten older, probably in self-interest as well as anything else. My understanding is it’s far more fluid now than it was when I was in my 20s and 30s. -law enforcement participant
	Chronological age	What do I think it means to be old? Well, I think it’s an age biologically; that’s how I view it personally. -health care participant
	Respect	More often than not I do see respect for the older populations, but there’s certainly a level of awareness I think that we could get to that would be at a higher level or maybe reach across different generations a little better. -health care participant

Table 2.

Sub-Categories, Codes, and Exemplar Quotes for the Individual Circumstances Theme.

Sub-Categories	Codes	Exemplar Quotes
Psychological factors	Caregiver burnout	What I’ve noticed is a lot of the abuse cases that we do get are more because the caretakers or caregivers are overwhelmed. They’re overwhelmed, they’re frustrated, they have lack of resources, so they don’t know how to properly provide or take care of the individual, and so the abuse is a result of the overwhelm-ment. -aging and victim service participant
	Denial	Because that it might happen to us is terrifying, we engage in this kind of minimization, or victim-blaming, or whatever you want to call it, as a defense mechanism. We don’t want to admit that it could happen to us. -law enforcement participant
	Fear	Why didn’t you call the police? I think fear is a huge thing; retribution is a huge thing probably. We don’t know as much about it. -health care participant
	Emotional attachment	Most of the time, we don’t even get it from the victim; we get it from another party, because that’s how strong the barrier is to implicating your own child…the victim just is not going to come forward most of the time unless it just gets so bad that they literally can no longer sustain the situation. -law enforcement participant
	Shame/Embarrassment	These relationship scams can go on for years.That is so painful on a variety of levels that people just say no, it’s got to be true, it can’t be a lie. So yeah, there’s a huge amount of that kind of psychology at play here, and then there’s shame, and humiliation, and embarrassment. -law enforcement participant
	Tolerating abuse	And it could be a spouse, family member, or someone else, but that just, I guess, tolerating it, and not speaking up, is an issue, too. -aging and victim service participant
	Trust	I would say that being a person who is maybe constitutionally more trusting makes one vulnerable. -law enforcement participant
	Retribution	You know, some people are just an easy target, and some people are afraid of making waves because what if there’s retaliation. -aging and victim service participant
	Psychological resistance	I think a lot of older adults, especially, it’s a generational effect, but I think currently we’re seeing a lot of baby boomers [who are] fiercely independent. -health care participant
	Guilt	I think there’s so much guilt, also. ‘My husband or my wife is this way and I just can’t do this, but we took those vows 70, 60 years ago, and I said in sickness and in health, till death do us part.’ -health care participant
	Trauma	Many victims are so traumatized by the experience that they’re not going to report it. -law enforcement participant
	Childhood trauma/abuse	Their ability to grow and to thrive in this setting, would be set up for better success if we can address their past in a way that sets some goals to improve their ability to cope with it and provide the support system that they would need through the professional rehab and therapy… -health care participant
	History of abuse	I would say with vulnerability that it could be stemming from a history of abuse, so maybe years ago they were abused, and it wasn’t talked about like it is today, and that just leads to now not saying anything as an elder. -aging and victim service participant
	Uncomfortable	It’s really difficult to face the uncomfortable reality that somebody is either declining and not going to get better or that they’re in an abusive situation, but we have to have the courage and the integrity to stand up for the people that we care about, and say we’re not just going to let this fester, we’re not going to let it get worse -law enforcement participant
Social Support	Social Isolation	And that leaves the isolation and all that, and you just become more of a vulnerable person as far as with predators. -aging and victim service participant
	Family	Sometimes if you can get family members in that help... there are all kinds of things that can be done, especially if we have a committed family member. -health care participant
	Cultural differences/values	When you look at other cultures, they really do rally around their elders, and they really put their elders at a higher level than what we do here in America. We’re not really elderly-focused, or we don’t take care of our older population the way other cultures really cover their elderly population, and they put them on high, whereas we don’t, over here. That’s not our culture. -aging and victim service participant
	Guardianship	Guardianship and having people that are willing to become guardians for people that may not have someone in the family that can or will be a guardian. -aging and victim service participant
	Power of Attorney	Most elderly people do not have a power of attorney or a medical directive, stuff like that that is very important for us in the later years. -law enforcement participant
Risk Factors	Vulnerability	If somebody is in an economically troubled situation, they’re much more susceptible to the types of swindles or scams that the thieves will use as an emotional hook. -law enforcement participant
	Crisis/desperation	We don’t want to get to the point where we’ve got [a crisis]. Unless people are in crisis, it’s actually harder to handle the situation than if you can detect the rising risk and try to help. -health care participant
	Abuse is the norm	There’s [sic] so many old people and there’s so much abuse, so it’s spreading it more thin, but that’s too thin, even accounting for just the volume. -health care participant
	Dementia	And actually, if dementia…comes in, you’re even more vulnerable. -aging and victim service participant
	Dependent	And when you are older, you do become dependent on someone younger that can help you and you rely on them, and when they’re abusive, it is scary to speak up because you don’t want to lose that connection. -aging and victim service participant
	Situational vulnerability	If we can identify that this person is vulnerable in some way, shape, or form, either because of a lack of capacity, or because of the situation, or because of an unhealthy relationship that they’re in. If we can identify that they’re vulnerable, we can set them up to hopefully avoid the worst of future abuses -law enforcement participant
	Predisposed because of medical condition	If you have medical debt or…if you are experiencing a health crisis and you’re desperate for some sort of relief, then it’s very easy for an abuser or a scammer to emotionally involve you, and to tweak you, and to get you on the hook to make a mistake, or to move too quickly, or to not stop and consider the big picture, because you’re already distracted, distressed, and under duress from your situation. -law enforcement participant
	Autonomy	Things are happening to you against your will. They sort of violate your autonomy and they’re to someone else’s advantage. -health care participant
	Abuse is cyclical/circular	I understand that prior past traumas increase your likelihood, statistically speaking, of being in abusive situations, and later in your life, if you’ve grown up with that, or become accustomed to that early in your childhood, for instance, domestic abuse tends to be a circular or cyclical issue. -law enforcement participant
	Taking away voice	…that I’ve seen and that I’m noticing is that a lot of elderly people lose their voice. And I don’t mean physically losing your voice, but they feel like they don’t have a say in some things, and so what I try to do is give that individual their voice, give them their voice back – ‘What is it that concerns you? I want to hear from you’ – and have that person be heard, because now you’re really showing that you are taking an interest in what concerns them. You’re giving them a voice that, I think, a lot of times, as people get older, society tends to put them on mute, so to say. So that’s the biggest piece, that I want to give the individual their voice. -aging and victim service participant
	Safety	If they’re competent and that’s where they want to be, we can do our best to help them be safe in their own environment, but we also have to respect their space. I think that’s an important aspect in older adults not losing their independence, or their independence not being taken away from them. There’s a fine line between that and when they truly are incompetent and unsafe, so I think when it comes down to that level of self-care, it’s about safety. -health care participant

Table 3.

Sub-Category, Codes, and Exemplar Quotes for the Nature of Abuse Theme.

Sub-Category	Codes	Exemplar Quotes
Type of Abuse	Targeting	…they had some sort of crisis in their life at the moment that made them particularly vulnerable to a phone scam, or to a romance scam, or something along those lines. Whereas, I’ve interviewed people who were in their eighties who I think anybody would consider to be a relatively aged person, who were intellectually very sharp, and I don’t think it was their age, per se, that was the primary risk factor for them. -law enforcement participant
	Predatory behavior	When you’re looking at financial abuse, it’s that person who’s looking for someone who doesn’t have a lot of ties in the community, someone who isn’t going to notice that they’re being manipulated, because of maybe social isolation. -aging and victim service participant
	Exploitation	I think that’s what we see; the older you get the more susceptible you are to different things. It’s been brought up before. Your physical abilities decline; your mental abilities decline, and people target you for different things. That’s what we deal with. -law enforcement participant
	Physical abuse	Sometimes people can get angry enough that physical violence occurs, like in dementia or something where the person is not cooperating; they’re not able to cooperate. The person doesn’t have enough training who’s providing the care and they get frustrated. -health care participant
	Sexual abuse	I’m sure that there probably is a lot of sexual abuse. That person who’s not consenting, and it can be a spouse, of course, that’s non-consenting, that isn’t able to tell anybody else. -health care participant
	Emotional/psychological abuse	It’s not that they’re preying on you because you’re old; it’s preying on you because you have loved ones, and they’re leading you to believe that your loved ones are in harm or in jeopardy, and it’s the emotional attachment that the elder feels to their grandchildren that is the hook for the scammer… -law enforcement participant
	Domestic abuse	It’s obvious when they make the 911 call because they can’t take it anymore or they’re at the hospital, but there’s so much of domestic violence we don’t see. -law enforcement participant
	Verbal abuse	For me it feels like discounting someone’s worth is the biggest form of abuse that at least I’ve seen in elders, like verbally. -health care participant
	Neglect	I think what I personally have seen as a healthcare provider has most often been, I’ll say neglect, and that is just not providing things that you’ve agreed to do. Whether it is responsibly managing someone’s finances versus using them for yourself, whether it is physically providing their care and not doing that, or removing their autonomy in decision-making, flat out, in ways that could potentially be harming that person. -health care participant
	Self-neglect	When self-neglect is happening because of a medical reason, not just because they’re okay living the way they’re living, and sometimes when they’re okay with living in an environment we don’t feel that I would be comfortable living in, we have to respect that. -health care participant
	Technology	Technology is changing day-by-day…I think that’s what we see; the older you get the more susceptible you are to different things. -law enforcement participant
	Escalation of abuse	It goes on for a long time because of that, so a lot of times what we’ll see with these kinds of elder financial abuse, or even elder physical abuse, is that this is a long-term, potentially very serious thing, and the victim just is not going to come forward most of the time unless it just gets so bad that they literally can no longer sustain the situation. -law enforcement participant

Results

Three major themes emerged from the data: societal influences, individual circumstances, and nature of abuse. Codes, sub-categories, themes, and exemplar quotes are in Tables 1 through 3.

Societal Influences

The societal influences theme consisted of four sub-categories: knowledge of abuse, addressing abuse, perceptions of resources and supports, and beliefs about aging.

Knowledge of Abuse

The sub-category knowledge of abuse included codes focused broadly on knowledge and education. In some instances, participants talked about abuse not being emphasized in their formal training. For example, one healthcare participant noted:

I did a master’s in hospital administration and that never came up.

Participants also discussed feeling unprepared to recognize abuse. Often, this was coupled with the need for greater public awareness of what constitutes abuse, such as in the following quote:

We want to prevent it, but we have to educate…we also need to start going into senior centers or church groups to get that out there… because there’ve been times when I’ve talked to someone that didn’t realize they were being abusive… that education to prevent it I think is huge. (Healthcare participant)

All of our participants believed greater awareness of what abuse is and how to recognize it is necessary for mitigating elder abuse. They also expressed willingness to take part in training to become better equipped to do this themselves.

Addressing Abuse

The second sub-category, addressing abuse, represented challenges within the current systems for addressing elder abuse. For instance, the processes for reporting abuse are often barriers, as captured below by a healthcare participant:

…the rules never seem to stay the same and so it’s really hard to help people when the rules keep changing and I can’t stay up on them…

Another healthcare participant shared that making the decision to report can be difficult, saying:

We spend a lot of time agonizing about whether or not APS [adult protective services] should be called.

Some participants expressed concerns about follow-up and case management. One law enforcement participant illustrated this, saying:

With that agency [Adult Protective Services; APS], with social services overall, normally they’re understaffed and overworked, have a heavy caseload…So when we call other agencies… the response is so delayed at times…you’ll call and they won’t call you back for another two hours…

Other participants discussed how legality and jurisdiction often make case management challenging. For instance, a law enforcement participant described working with other community partners saying:

Generally speaking…our first calls are typically to financial institutions, mental health clinicians sometimes… and department of social services…None of those work for law enforcement, so I can’t tell them what to do.

This perceived lack of linkage between various community systems and agencies was shared by other participants, as evidence by the following statement:

…I’ve been in the field for a long time… it would just be nice to see a linking of the systems so that advocates and people actually working in the field know who they can turn to for certain types of assistance. (Aging and victim service participant)

Another law enforcement participant discussed how a more connected infrastructure would better serve older adults, saying:

…Many hands lighten the load, so the more interconnection and intercommunication between all the players that end up interacting with seniors and to make sure that they get the law enforcement assistance or the APS [adult protective services] assistance.

In addition to better connecting systems involved with elders, our participants discussed challenges posed by a system structured around response rather than prevention of abuse. This observation is captured by the following participants’ statements:

Unless people are in crisis, it's actually harder to handle the situation than if you can detect the rising risk and try to help…I often find that we are seeing the rising risk and can see what’s going to happen… and we’ll call them, and nothing happens, like they can’t do anything. (Healthcare participant)

A law enforcement participant commented on the lack of funding for responding to elder abuse saying:

…it’s almost like they need to see the cases [of elder abuse] to justify providing more money. So instead of it being a, “Hey, let’s give you the funding to prevent these things from happening,” it’s, “Okay once we have enough cases, then we can justify giving you the money.” And that’s totally backwards.

Similarly, another law enforcement participant elaborated on “things they catch too late” saying:

When…all the money is gone…when they show up to the hospital with malnutrition or they have a break…”Well, she fell.” She fell three months ago, too. “You’ve got to be more careful. How is the house set up?” Those are things we catch late.

Our participants all seem to believe that better systems and structures for recognizing and preventing elder abuse from happening is crucial to more efficient response.

Perceptions of Resources and Supports

The third category within the social influences theme offered some insight about how participants view the current structures and policies for addressing elder abuse. For example, many participants described pitfalls of the current system, indicating the existing systems and policies leave them feeling as if they are unable to have a positive impact, which this healthcare participant quote expresses:

…I can think of one example where the person got the help they needed…But most of the time I don’t see a real change in the circumstances, except that I now have no relationship with the person that this happened to. [Laughs] Maybe it’s that we didn’t know when was the right time. Like I said, I don’t remember it being a part of my training as a health professional on when you should call…Maybe there’s just limitations of what can be accomplished through that route… I felt like the situation was actually worse afterwards.

Participants also believed that abuse of older adults is not a societal priority and that this contributes to an ineffective and inefficient structure for responding to elder abuse including, but not limited to, overloaded systems and insufficient resources. This is evidenced by the following healthcare participant quote:

… every new administration we get… they’re all into something new. It would just be nice… if there were some societal, structural appreciation for aging, but a lot of the policies seem to be made by the generation before that hasn’t gotten to aging.

In other instances, participants feel as though they do not have the resources they need to properly advocate for older adults, saying:

…it makes me feel like I don’t have the appropriate support I need to advocate for these individuals. (Aging and victim service participant)

Other participants discussed what they feel is “societal blindness” to aging, saying:

…I think there’s some societal blindness to issues around aging...Issues around aging are so twisted up, because people just don’t want to deal with it…it seems possible that this area of our society is just kind of ignored because oh, Grandma’s in a home and these are just the sort of things that happen to old people…There have been elected officials who have made public statements that we should write off our elderly. Yikes. Can you imagine a statement like that made about any other population…? It would be staggering. (Law enforcement participant)

Other participants seemed to believe that the current structure and inadequate resources within it is more than mere “societal blindness” but is actually due to a lack of value on older adults, illustrated by this aging and victim service participant:

It makes me feel that there’s little value on older adults…And so that just makes me feel like they’re saying, Well, they’ve lived their life. They don’t need anybody to advocate. They’re not going to be here much longer anyway.

In addition to commenting on society’s beliefs about aging, many participants also commented on various beliefs individuals have about aging and how that contributes to an overall, societal de-valuing of older adults.

Beliefs About Aging

Codes aligning with the sub-category beliefs about aging, illustrated the range of beliefs individuals have about aging, with the most prominent code being ageism. Within our data, ageism was both explicitly expressed as well as described as a symptom of our society. Explicit ageism was expressed as excuses to explain away instances of elder abuse or blame victims for their own abuse and neglect. Examples of ageism being explicitly expressed included the following:

…and it doesn’t have to be physical or abusive but could be more like neglect, like, “I don’t have time to go get your groceries or take you to the doctor. So be it. Deal with it,” you know. And usually, the seniors aren’t really proactive. They just lie back and accept whatever. (Aging and victim service provider)

Some of the instances of explicit ageism that were expressed stereotypes applied to older adults, such as the following statement made by a healthcare professional:

It’s an older person, so we expect them to be incapacitated in some ways. Like they should be dependent on this other person and…Well, what do you expect? Sure, they smell like urine and they’re not caring for themselves, but they’re old and that’s how it goes. These are sort of an acceptance of things in an older person that you wouldn’t accept in a younger one.

Participants discussed many other stereotypes of older adults that exist in our society, including stereotypes such as older adults don’t like to use the internet or computers, that they tend to live life more “slowly” than young people, that “boomers are fiercely independent,” and that they are more vulnerable. Participants also recounted how ageism can lead professionals to miss or explain away forensic indicators of abuse. One law enforcement participant shared the following story regarding stereotypes present in society:

…we get a lot of…calls, where something will start in the emergency room…The ER will report something…They make a report, it comes to us, we investigate it. Then we talk to the next doctor, the specialist, and the specialist is like, “you know, for their age and their mobility, it’s a completely normal injury”…there’s a disconnect between intake and the specialists.

Overall, our participants seem keenly aware that our society’s ageist beliefs and attitudes contribute to a perpetuation of and dismissal of elder abuse.

Individual Circumstances

Three sub-categories comprised the second major theme of individual circumstances: psychological factors, social support, and risk factors.

Psychological Factors

Codes aligning with the psychological factors sub-category represented various psychological and emotional reasons an individual might tolerate, commit, or excuse abuse. Caregiver burnout was frequently discussed as an excuse for abusing an older adult, as evidenced by the following statement:

…what I also see or what I’ve noticed is a lot of the abuse cases that we do get are more because the caretakers or caregivers are overwhelmed. They’re overwhelmed, they’re frustrated, and they have lack of resources, so they don’t know how to properly provide or take care of the individual, and so the abuse is a result of the overwhelm-ment. (Aging and victim service participant)

Childhood trauma or other histories of abuse were also discussed as reasons abuse may be normalized or tolerated. Other reasons given for toleration of abuse included fear, emotional attachment, shame, guilt, and retribution; most participants had stories they could tell about why someone had struggled to seek help when they were experiencing abuse, such as in the following example:

Domestic abuse is always messy… and I think with elder abuse it’s especially bad, because what if it’s a child that’s taking advantage of you—your own child… So if you’re an elder and your adult child is taking advantage of you, imagine the psychological resistance to coming forward with that report. (Law enforcement participant)

Apart from struggling with emotional abuse, particularly when loved ones are the perpetrator of abuse, many participants discussed the difficulty of admitting to one’s self that they have been taken advantage of, such as in the following law enforcement quote:

When you talk about the embarrassment and the humiliation… But the extreme cognitive dissonance of admitting to yourself yep, I got taken in and now I’m on the hook for a lot of money is really painful. People will tend to just double down.

Our participants discussed a number of incidents they have encountered in their work where older adults were struggling, both emotionally and psychologically, to accept what was happening to them was actually abuse committed by either loved ones or by strangers.

Social Support

Codes aligning with the second sub-category in the individual circumstances theme captured the role of a person’s various social supports in abuse. Family was discussed a great deal, both as a means of social support as well as a source of perpetrators of abuse. Some participants commented on cultural differences in familial care of older adults with comments such as:

…we really see a vast cultural difference in families that will stay together in a community and families that feel that they must put their loved ones in a nursing facility. (Aging and victim service participant)

Being isolated from family was also discussed as a reason why elders might experience abuse or why abuse may go undetected for so long. Some participants reflected about elders in their own family and wondered how things might be different if they weren’t involved in caring for them, such as the following aging and victim service participant’s reflections of their own father:

The other thing I’d like to mention here is maybe self-neglect as people get older. I take food to my father…My sister is able…to order his welding supplies and anything else that he needs. But I think it would be a different situation if he did not have us…I think he would be a bit neglectful…

Overall, our participants viewed social networks as both an opportunity for protection against abuse and neglect as well as a potential gateway for abuse and neglect to occur.

Risk Factors

The final sub-category in the individual circumstances theme, risk factors, highlighted traits that make older adults vulnerable to abuse. For example, many participants said older adults are vulnerable simply because they are old. Being in a crisis or state of desperation was mentioned as being both a risk factor for an older adult becoming a victim of abuse as well as something that might make a perpetrator more likely to commit abuse, such as in this quote:

I would say that anytime that you’re emotionally involved…in some sort of desperate circumstances… and you’re desperate for some…relief, then it’s very easy for an abuser…to get you on the hook to make a mistake…because you’re already…under duress from your situation. (Law enforcement participant)

Other risk factors included living with dementia, being dependent, having certain medical conditions, lacking autonomy, or the fact that society seems to take away the voice and autonomy of older adults.

Nature of Abuse

Only one sub-category—Types of Abuse—emerged in the nature of abuse theme though 12 individual codes aligned with this theme. These codes focused on what abuse actually looks like. Many participants discussed targeting and “romance scams” when talking about elder abuse. Technology was frequently mentioned as a modality for committing abuse. Others described situations in which domestic or verbal abuse was taking place or neglect on the part of a caregiver or the older adult themselves. Many participants listed various types of abuse they were familiar with or frequently encountered in their field, such as the following participants’ reflections:

I think it can look like a lot of things. Doing things against your will...It could be mental in not allowing you decision-making…It could be injury. It could also just be neglect, not caring for someone that you’ve accepted obligation to care for…It could even be financial, exploitation… I think of…different kinds of ways it could manifest.

Similarly, several participants also reflected on the type of abuse they most encountered through their work. Our participants appeared to have experienced or dealt with most forms of abuse as a professional.

Discussion

Our purpose was to gain understanding of the knowledge of abuse and beliefs about current practices among Virginia’s frontline workforce. Three major themes emerged from our data: societal influences, individual circumstances, and nature of abuse.

Within the Societal Influences theme, our data highlighted the need for increased training on elder abuse targeting frontline workers and the general population, especially older adults and their caregivers. Participants frequently discussed the challenges to reporting abuse, citing barriers such as ever-changing policies and the inability for systems of care to communicate with one another about cases. These findings echo those of Gonzalez and colleagues (2016), who found that emergency medical technicians were eager to work more effectively with Adult Protective Services (APS) but needed more training, better policies, and less time-prohibitive avenues for screening and reporting. Our participants also believed that protecting older adults is not a societal priority; they provided a number of ways in which this plays out in their work, including the provision of inadequate resources and a lack of focus on prevention. This finding supports the work of Pillemer and colleagues (2021), who proposed an ecological systems framework for elder abuse wherein ageism impacts action at the societal level.

Within the second major theme, Individual Circumstances, participants discussed a number of factors specific to an individual that might make them vulnerable to or tolerant of abuse; this included social isolation and several psychological factors such as fear, guilt, and denial. Factors that placed some at greater risk of committing elder abuse were also discussed by participants and included things such as caregiver burnout and financial distress. These findings align with the Abuse Intervention Model (AIM; Mosqueda et al., 2016); AIM is a framework for identifying and addressing risk for elder abuse in three domains: the vulnerable older adult, the trusted other, and the context of their relationship (Mosqueda et al., 2016). Specifically, the purpose of the AIM framework is to identify potential risk factors for abuse for the vulnerable older adult (potential victim), the trusted other (potential perpetrator), such as a caregiver, spouse, or child, and the relationship between them. Our participants discussed various risk factors they identified within a variety of older adult-trusted other dyads, highlighting that it is not always just risk factors an older adult has but, rather, risk factors exist within and between older adult-trusted other dyads.

The third theme, Nature of Abuse, highlighted the various experiences our participants had with abuse. In many instances, participants told stories involving certain kinds of abuse. For instance, “romance scams” and other types of predatory behaviors were commonly mentioned. All forms of abuse were discussed by our participants and their encounters highlight how complex and unique each instance of elder abuse is. Importantly, this finding points out the need for education and training on all types of abuse and how to recognize warning signs, both covert and overt, for each type of abuse. Participants also gave countless examples of older adults who were ignoring, tolerating, or justifying abusive behaviors for various reasons. Given that our sample consisted of all frontline practitioners within a community, it is important that future research and education expand previous efforts by aiming to ensure the broader public, such as older adults themselves and their caregivers are also educated about what abuse is and how to recognize and respond to it.

Though not a stand-alone theme, ageism was present within our data across several themes and sub-categories. Ageism is the prejudice or discrimination against people based on age (Butler, 1969) that can be expressed implicitly or explicitly (de Paula Couto & Wentura, 2017; Levy & Banaji, 2002). Our participants expressed a strong belief that older adults are not valued by society. It is possible that society-at-large does not intentionally deny resources and services that support the safety of older adults but, instead, is the result of their collective implicit and negative bias toward older adults. Explicit ageism was also present in our data through several instances of ageist beliefs and stereotypes being expressed such as the belief that older adults are vulnerable, are frail, and smell of urine.

Our findings support and expand current research on elder abuse and, specifically, support the utility of the AIM and ecological systems models for identifying risk factors at multiple levels in an older adults’ environment and not just risk factors of the older adult themselves may. Though our findings suggest that ageism’s role in abuse is prominent, more research is needed to uncover the theoretical and empirical relationships between ageism and elder abuse. Future efforts should also seek to use the AIM and ecological systems models to identify opportunities for preventing elder abuse from occurring. Finally, this work points to the need for more interconnected, resource- and knowledge-rich agencies, policies, structures, and systems to effectively intervene and reduce the prevalence of elder abuse.

Implications

Our findings suggest that a critical step toward safeguarding older adults is to reduce ageist attitudes and beliefs held by individuals within the community. These findings align with The World Health Organization (2022), which recommends combating ageism as the top priority for addressing elder abuse worldwide. We also heard a call to invest in training and education from our participants. Future research on elder abuse should focus on the development and evaluation of more evidence-based training for our frontline personnel as well as older adults and caregivers of older adults. With increased knowledge, those best positioned to intervene when abuse occurs can do so more effectively, efficiently, and confidently. Providing similar education and training opportunities to the general population also serves as a means for safeguarding older adults. The more our society knows what abuse is, how to report it, and effective strategies for prevention, intervention, and treatment, the more likely that instances of elder abuse will be reduced.

Limitations and Conclusion

This study focused on frontline workers located in central Virginia, limiting the generalizability of our findings to similar demographics in other states or countries. Areas with more resources and robust social support available to older adults, such as municipalities that have active multidisciplinary teams (MDTs) for elder abuse response, might not have the same difficulties working across disciplines and agencies discussed by our participants (e.g., DePrince et al., 2019). The COVID-19 pandemic limited participant recruitment and availability, particularly frontline healthcare workers, due to increased workloads and staff shortages. This resulted in several focus group sessions where only one participant was able to attend. These participants were eager to participate and share their insight and valued the study topic. We wanted their voices to be included in the study and did not remove them from data analysis. Having to conduct focus groups via teleconferencing software also posed challenges recruiting from rural areas where broadband access is more limited. Knowing the conversations were recorded might have deterred some individuals from being completely honest in conversations about such sensitive topics. Finally, we did not collect additional demographic information about our participants, further limiting generalizability. Despite these limitations, our findings are consistent with other literature on elder abuse recognition. Moreover, our findings set the stage for future research and advocacy efforts that will ultimately be effective in reducing the prevalence of elder abuse.

Supplemental Material

Supplemental Material - An Exploration of the Knowledge and Current Practices of Frontline Workers Regarding Elder Abuse

Supplemental Material for An Exploration of the Knowledge and Current Practices of Frontline Workers Regarding Elder Abuse by Sarah A. Marrs, Miranda Yelvington, Annie Rhodes, Courtney O’Hara, Catherine MacDonald, and Tracey Gendron in Journal of Applied Gerontology.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Virginia Commonwealth University Presidential Research Quest Foundation.

IRB Protocol Numbers

HM20020135.

ORCID iDs

Sarah A. Marrs

Miranda Yelvington

Tracey Gendron

Supplemental Material

Supplemental material for this article is available online.

References

Acierno

Hernandez-Tejada

M. A.

Anetzberger

G. J.

Loew

Muzzy

(2017). The national elder mistreatment study: An 8-year longitudinal study of outcomes. Journal of Elder Abuse & Neglect, 29(4), 254–269. https://doi.org/10.1080/08946566.2017.1365031

Braaten

K. L.

Malmedal

(2017). Preventing physical abuse of nursing home residents as seen from the nursing staff’s perspective. Nursing Open, 4(4), 274–281. https://doi.org/10.1002/nop2.98

Braun

Clarke

(2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101. https://doi.org/10.1191/1478088706qp063oa

Butler

R. N.

(1969). Age-ism: Another form of bigotry. The Gerontologist, 9(4), 243–246. https://doi.org/10.1093/geront/9.4_Part_1.243

Chang

E. S.

Levy

B. R.

(2021). High prevalence of elder abuse during the COVID- 19 pandemic: Risk and resilience factors. American Journal of Geriatric Psychiatry, 29(11), 1152–1159. https://doi.org/10.1016/j.jagp.2021.01.007

Daly

Coffey

(2010). Staff perceptions of elder abuse. Nursing Older People, 22(4), 33–37. https://doi.org/10.7748/nop2010.05.22.4.33.c7735

de Paula Couto

M. C. P.

Wentura

(2017). Implicit ageism. In Ageism, stereotyping and prejudice against older persons (pp. 37–76). The MIT Press. https://doi.org/10.7551/mitpress/10679.003.0006

DePrince

A. P.

Hasche

L. K.

Olomi

J. M.

Wright

N. M.

Labus

(2019). A randomized-control trial testing the impact of a multidisciplinary team response to older adult maltreatment. Journal of Elder Abuse & Neglect, 31(4–5), 307–324. https://doi.org/10.1080/08946566.2019.1682097

Dong

X. Q.

Simon

M. A.

(2013). Elder abuse as a risk factor for hospitalization in older persons. JAMA Internal Medicine, 173(10), 911–917. https://doi.org/10.1001/jamainternmed.2013.238

10.

Gonzalez

J. M. R.

Cannell

Jetelina

K. K.

Radpour

(2016). Barriers in detecting elder abuse among emergency medical technicians. BMC Emergency Medicine, 16(1), 36. https://doi.org/10.1186/s12873-016-0100-7

11.

Lachs

Berman

(2011). Under the radar: New York state elder abuse prevalence study. Self reported prevalence and documented case of surveys final report. Lifespan of Greater Rochester, Inc., Weill Cornell Medical Center of Cornell University, New York City Department of Aging.

12.

Lachs

M. S.

Williams

C. S.

O’Brien

Pillemer

K. A.

(2002). Adult protective service use and nursing home placement. The Gerontologist, 42(6), 734–739. https://doi.org/10.1093/geront/42.6.734

13.

Levy

B. R.

Banaji

M. R.

(2002). Implicit ageism. In Nelson

T. D.

(Ed.), Ageism: Stereotyping and prejudice against older persons (pp. 49–75). The MIT Press.

14.

Mosqueda

Burnight

Gironda

M. W.

Moore

A. A.

Robinson

Olsen

(2016). The abuse intervention model: A pragmatic approach to intervention for elder mistreatment. Journal of the American Geriatrics Society, 64(9), 1879–1883. https://doi.org/10.1111/jgs.14266

15.

National Center for Injury Prevention and Control . (2021). Preventing elder abuse fact sheet. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Division of Violence Prevention. https://www.cdc.gov/violenceprevention/pdf/elder/preventingElderAbuseFactsheet.pdf

16.

Pillemer

Burnes

MacNeil

(2021). Investigating the connection between ageism and elder mistreatment. Nature Aging, 1(2), 159–164. https://doi.org/10.1038/s43587-021-00032-8

17.

Rosen

Bloemen

E. M.

Harpe

Sanchez

A. M.

Mennitt

McCarthy

T. J.

Nicola

Murphy

K. C.

LoFaso

V. M.

Flomenbaum

N. E.

Lachs

M. S.

(2016). Radiologists’ training, experience, and attitudes about elder abuse detection. American Journal of Roentgenology, 207(6), 1210–1214. https://doi.org/10.2214/ajr.16.16078

18.

Rosen

Stern

M. E.

Mulcare

M. R.

Elman

McCarthy

T. J.

LoFaso

V. M.

Bloemen

E. M.

Clark

Sharma

Breckman

Lachs

M. S.

(2018). Emergency department provider perspectives on elder abuse and development of a novel ED-based multidisciplinary intervention team. Emergency Medicine Journal, 35(10), 600–607. https://doi.org/10.1136/emermed-2017-207303

19.

Saldaña

(2016). The coding manual for qualitative researchers. Sage Publications.

20.

United Nations Department of Economic and Social Affairs, Population Division . (2022). World population prospects 2022: Summary of results. https://www.un.org/development/desa/pd/sites/www.un.org.development.desa.pd/files/wpp2022_summary_of_results.pdf

21.

U.S. Centers for Disease Control and Prevention . (2024). About abuse of older persons. https://www.cdc.gov/elder-abuse/about/index.html

22.

Wong

J. S.

Waite

L. J.

(2017). Elder mistreatment predicts later physical and psychological health: Results from a national longitudinal study. Journal of Elder Abuse & Neglect, 29(1), 15–42. https://doi.org/10.1080/08946566.2016.1235521

23.

World Health Organization . (2022). Tackling abuse of older people: Five priorities for the United Nations decade of health ageing [2021–2030]. https://www.who.int/publications/i/item/9789240052550

24.

Yon

Mikton

C. R.

Gassoumis

Z. D.

Wilber

K. H.

(2017). Elder abuse prevalence in community settings: A systematic review and meta-analysis. Lancet Global Health, 5(2), e147–e156. https://doi.org/10.1016/S2214-109X(17)30006-2

25.

Yunus

R. M.

Hairi

N. N.

Choo

W. Y.

(2019). Consequences of elder abuse and neglect: A systematic review of observational studies. Trauma, Violence, & Abuse, 20(2), 197–213. https://doi.org/10.1177/1524838017692798

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