Violence against the elderly is a reality, which, although relatively hidden in some societies, has been gaining a growing visibility and concern for decades throughout the world.

The first studies on violence against the elderly dates back to the 1970s, with an emerging publication in 1975 in the British Medical Journal, entitled “Granny Battering” written by Burston1. Since then, and especially since the end of the last century,^1,2 the awareness of this social problem has begun to attract the interest of researchers, academics and professionals in the field, who dedicate themselves exclusively to this topic. This problem is highlighted in several areas, namely in health (Gerontology), due to the serious implications of this phenomenon on longevity and individuals quality of life,³ but also in other areas of science such as Psychology, Sociology or Criminology. With research developed in the 1990's, violence against the elderly is mainly understood as family violence, often perpetrated by caregivers or close associates, sometimes with associated psychopathology.¹

Violence against the elderly is now recognized as a health problem, which compromises not only individual and family adjustment, but also the development of society. This violence is defined as “an intentional act or failure to act by a caregiver or another person in a relationship involving an expectation of trust that causes or a risk of harm to an older adult”.⁴ This definition is consistent with the 1995 proposed definition by the International Network for Prevention of Elderly Abuse (INPEA), which is generally adopted in most documents and manuals (cf. Portuguese Association for Victim Support, APAV, 2010) to define violence perpetrated against a person aged 60 or over.

This text is intended to discuss the phenomenon of violence against the elderly as a social problem that must cause us grave concern for the serious violation of the dignity of the human person, for the risk and harmful implications for the integrity and well-being of the elderly person, and in general, for their lives in society.^5,6 In this sense, we will give a brief explanation of aspects that characterize the phenomenon of violence against the elderly, ending with the exposition of an example case of the phenomenon.

Violence against the elderly is not simple to characterize, as its description depends on a number of factors, including context of occurrence, proximity between victim and aggressor and various forms of aggression. For this reason, there is often no consensus as to the terms to use, with a diversity of concepts employed, such as “maltreatment”, “violence” or “abuse”.^7,8 The absence of conceptual consensus is such that, perhaps, what matters most is to pay attention to the problem and realize that this phenomenon happens more often than one might think⁹ and that our aim should be to protect the elderly person who is in a situation of vulnerability, fragility or dependence on a caregiver who is violent or abusive.

One of the difficulties is to identify the victim, because he is not always aware or understands that certain abusive behaviours are violence. For example, recurrent absence of satisfaction of basic needs (e.g., food, hygiene, affection) may be interpreted by the elderly as caretaker unavailability rather than intentional or harmful behaviour. 

In this way, such situations are not reported by the elderly person, and their lack of signaling can make resolution difficult. However, this violence does not necessarily imply a violent action; however, the absence of care, which is often continuous, may constitute an abuse situation.¹⁰ It is also possible for the elderly person to be aware that they are victims of violence by their caregiver and be afraid to report the abuse. Difficulties in seeking help often arise from the embarrassment and fear caused by violence, especially because it is often perpetrated by close family members (e.g., spouse, children, grandchildren), on whom they depend as the sole caregiver.¹⁰

Violence against the elderly person may exhibit different forms^11,4,12 such as: (I) Physical violence (e.g., push; hit; hurt; shake; bind someone which can fracture bones, force someone to eat or drink, pull hair, burn with cigarettes or liquids, force someone to be in an improper posture); (II) Psychological / Emotional Violence (e.g., threatening, making unjustifiable accusations, harassing, bullying physically or verbally, infantilizing the person, limiting the person’s rights to privacy, making a decision, obtaining medical information, voting or receiving any mail and communicating with others); III) Economic / Financial Violence (e.g., use the economic resources of the elderly, coerce for the signing legal documents, such as wills, statutes of assets, etc.); (IV) Negligence or neglect (e.g., not ensuring proper nutrition, not helping to take care of hygiene or leaving them in an unhealthy environment, neglecting the state of hydration, not treating wounds or injuries, leaving the elderly person in bed, on the street or in public institutions). Other authors^13-16 also mention, in a prominent way, physical or sexual violence, which refers to actions, aimed at arousal, sexual intercourse or erotic practices through grooming, physical violence or threats.

Violence perpetuates changes in the elderly person’s life situation, generating fear, and concerns about their safety, diminishing their quality of life, confidence and self-efficacy in others, as well as producing injuries, disabilities, disfigurations or even death, particularly as a result of physical violence.⁴

Despite the diversity of abuse found in the literature, both concerning the concepts that define violence against the elderly person as well as the determination of typologies and forms of victimization, research^15,12,17,20 has been unanimous in pointing out the existence of risk factors, which with varying degrees of evidence18 arise related to the victim himself, the aggressor and the environment where it occurs. With regard to the victim, some of the factors contribute related, to old age, sex (with a higher definition of risk in case of being a woman), low social support, social isolation, dependence due to physical or mental factors, among others.^18,19 On the other hand, aggressor characteristics such as financial dependence on the victim, mental illness or substance use appear as frequently reported aspects of the risk of violence against the elderly.^19,20  It is also important to emphasize the environment of occurrence, being the family and the institutional contexts, which are the most frequently, identified risk factors of violence against the elderly.²¹

The prevention of violence against the elderly presupposes, first of all, that the factors that put them in a situation of vulnerability are known, if we are able to identify these risk factors, we can act to reduce or eliminate them, thereby preventing the development of new cases or the negative progression of existing situations. Our understanding of these factors also contributes to the mobilization of public prevention policies.

A number of countries have made efforts to increase prevention strategies, ranging from developing projects and primary prevention advertising campaigns focused on this specific form of violence, to the specialized training of first-line professionals (such as nurses, doctors and police) or legal actions in cases of violence against the elderly.

In fact, it is necessary to provide information that is sensitive to all, and it is important that the community is involved in activities to reduce and prevent violence against the elderly. Examples of these are activities include involving different generations for times of sharing and affection (e.g., reading, walking), as well as awareness raising actions by professionals working with elderly people, alerting them to the need for help, to avoid possible financial exploitation or other types of violence and disrespect of their rights. The training of professionals, aiming to improve the care or information provided to the elderly victim of violence, as well as the dissemination of training and information materials and manuals11 are among the efforts to reduce risk and contribute to targeted and specialized support for the elderly. Such measures, combined with the effective application of legal sanctions and programs to protect elderly victims of violence, reinforce the fight against this criminal phenomenon.

Finally, a case of violence against an elderly person is presented, in order to illustrate one of the aspects mentioned above.

Madeline is a 68 years old female, who is suffering from family violence committed by Peter, who is 37-year-old, and her youngest son; Madeline was able to describe her situation of violence.

Madeline was married to the father of their four children for 34 years. The couple had three sons and one daughter. Harry, 48 years old, followed by Paul 46 years old, and Helen, who is 40 years old. Madeline is now divorced, but she and her husband, John were owners of a shoe business. Madeline is now retired. Peter has always followed his father and he helped in the family business, and has decided to live with the father at the time of their divorce. The three others stayed with their mother.

Madeline was able to raise their children in spite of several financial difficulties. Helen bought a house with the condition that once she got married and left home, her youngest brother would take care of their mother, and secondly that the house should belong to their mother until her death, however Peter, got married, he left house as well, and Madeline was left - living alone.

Peter was divorced months after his marriage, apparently due to alcohol problems, which turned into a chronic problem and has declined every proposed treatment. Like Madeline said “… he had a lot of girlfriends but no one wanted to marry him probably because of the alcohol...he used to drink a lot”. After Peter divorce, he returned to his mother’s home.

One time he was completely drunk, and decided to turn his mother home into a gambling house. When his mother complained, he became violent towards her. Madeline remembered “I thought the time arrived to put an end and I told him …’this is not a gambling or prostitution house... I thought it would arrange everything but unfortunately, and on the contrary, it turned everything against me… screaming he told me that the house was his and not mine…and after that moment he started to insult me”.

Several months after these events, Harry was also divorced and also had an alcohol problem. Madeline said “I realized that my oldest son had a drinking problem as well, which was the reason of his divorce... At least he has a job, but after work, he arrived always drunk at home… beer and cheap cognac only …several months after, his boss decided to downsize the company and my son was unemployed. But drinking was not the problem, because he was already an alcoholic before, and when sober he is adorable” she referred.

Madeline decided to get help for both their sons and their alcohol dependence, and in the meantime their family doctor prescribed her an anti - depressive medication, in order to help her cope with the situation (cipralex®-Escitalopram 10 mg). Both her sons were admitted to a psychiatric hospital and several drugs were prescribed such as: Anafranil® (clomipramine hcl) twice a day, Doluron F® (Codeine phosphate hemihydrate+ Acetaminophen) twice a day, Omeprazole 40 mg every morning, and Guronzan®. (Ascorbic Acid+Caffeine+ Glucuronamide) when needed.

After discharge, they refused to follow the hospital doctor’s prescription, and their condition got more severe each day. Subsequently, Peter, the youngest son, beat his mother so badly that she had to be transported to the local hospital.

The violence started with insults, and escalated into utter chaos. There was also violence in the street, and police had to be called. Because of high risk of violence, Madeline had to leave her own house and moved into her sister’s home in an emergency after another episode. Madeline remembers that “The police officer told my sister that if I showed up at home that there was going to be a tragedy.”

Her friends are a major support. Her daughter helped her some of the time but not on a regular daily basis. From Paul, she has no support. Madeline said frequently “they have their own lives you know”.

Her own sister, who was married to a lawyer, stated that she didn’t want any troubles, so that Madeline had to return to her own house soon after her recovery.

Nowadays, Madeline expressed a high degree of anxiety, and is deeply perturbed, after several years of victimization. She is being followed by the family doctor and medicated with anti-depressives. She wishes for the successful treatment of both their sons, and not their arrest. Madeline needs protection and to live in a context of respect for her rights, without risk of being a victim of several forms of violence.

She finally decided to take a complaint against her own son, and her case was referred to the Department of Investigations and Penal Action.

The present case shows the problematic situations discussed in this article about violence against elderly. It shows a true case of violence within the family, perpetrated by a family member.

Throughout this brief case description, several risk factors were shown, some of them related to the individual nature associated with the aggressor, such as an alcohol and gambling addiction, which had affected in a short term, both, his mental e physical health. Apart from the described risk factors, others of more circumstantial natures can be seen, such as the aggressor economic dependence motivated by his unemployment, and consequently the need of cohabitation with the victim.

The combination of these factors with others linked to the victim (e.g. physical vulnerability linked with her age, loneliness, lack of social and family support), are among the indicators described in the literature as risk factors against the elderly.

In the present case, physical violence episodes demanded medical care, as well as negligence and abandon - by her supporters (e.g. daughter). Madeline’s daughter believed her option was to minimize the facts, and therefore she did not give any affective support to the victim in spite of the evidence of abuse.  This elderly clinic scenario also demonstrates that the situation can become severe, such as the development of symptoms of depression that require specific treatment.

Madeline was in fact, a reported domestic violence victim, but in spite of the high and visible risk indicators, it took a long time to obtain social visibility. The knowledge and the specific expertise needed for this case, is undoubtedly, a criteria sine quo non for a preventive approach as well as an intervention, which can achieve reducing the violence against the elderly.

None.

The authors declare no conflict of interest.

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