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Investigating the connection between ageism and elder mistreatment

Abstract

Elder mistreatment is recognized as a pervasive public health problem with detrimental consequences for older adults and society. Although considerable research has examined elder mistreatment risk factors at the individual level, there is a growing call for the field to move beyond proximal causes and consider underlying structural factors that influence elder mistreatment. Illustrating this shift, organizations, advocacy groups and researchers have proposed a connection between ageism and elder mistreatment. However, despite the assertion that ageism is a causal factor for elder mistreatment, there is a scarcity of research to demonstrate this relationship. In this Perspective, we examine the proposed conceptual pathways and limited empirical research connecting ageism and elder mistreatment. After identifying critical gaps in current knowledge, we propose a model that links ageism and elder mistreatment and a research agenda to bring conceptual clarity and empirical evidence to the study of this topic.

Main

Elder mistreatment is a significant public health problem that is receiving global attention from the medical community, social service providers and policymakers. This concern is heightened by the rapid aging of populations around the world, which both expands the number of individuals susceptible to elder mistreatment and strains the service systems that prevent and treat the problem. Prevalence estimates suggest that as many as 10% of older people experience one or more forms of elder mistreatment1. Research has demonstrated the highly detrimental mental, physical and economic consequences of elder mistreatment2 as well as damaging ripple effects on other family members3. For these reasons, the World Health Organization has made preventing and treating elder mistreatment a key priority in its World Report on Ageing and Health4.

Definitions of elder mistreatment have varied across research studies, making their results difficult to compare. Consensus has emerged, however, around a definition proposed by a US National Academy of Sciences panel. This panel defined elder mistreatment as (1) intentional actions that cause harm or create a serious risk of harm (whether or not harm is intended) to a vulnerable older person by a caregiver or other person who stands in a trust relationship to the older individual or (2) failure by a caregiver to satisfy the older person’s basic needs or to protect him or her from harm (elder neglect)5. The central facet of this definition is that an older person has been subjected to actual or threatened harm by a specific individual who is in a responsible position with respect to the older person.

Further, there is widespread agreement on the main actions that constitute elder mistreatment (Fig. 1). ‘Physical abuse’ includes direct physical force likely to cause pain or injure an older individual. ‘Elder neglect’ involves failure to provide care, medicine, food and other necessities by a designated caretaker. ‘Psychological abuse’ represents actions carried out with the intent of causing psychological distress, such as threats, intimidation or insults. ‘Sexual abuse’ of older individuals has also been identified, including inappropriate touching and forced sexual activity. ‘Financial exploitation’, a rapidly growing phenomenon, involves the misuse of an older person’s financial resources, through theft, coercion, fraud or other means.

Fig. 1: Elder mistreatment subtypes.
figure1

Physical abuse refers to direct force causing pain or injury. Neglect refers to failure to provide services necessary to maintain physical and mental health. Psychological/emotional abuse refers to actions causing psychological or emotional distress, including threats, intimidation and insults. Sexual abuse refers to forced or unwanted sexual activity, including inappropriate touching and sexual harassment. Financial abuse refers to unjust, improper and/or illegal use of resources, property and/or assets.

Research on elder mistreatment has advanced significantly over the past two decades, although numerous gaps remain. Prevalence studies have proliferated; a recent systematic review uncovered 56 scientifically acceptable prevalence studies from around the world6. Improved methods in recent studies have allowed clearer specification of the extent of elder mistreatment. The scientific literature on the effects of elder mistreatment also has grown rapidly, with clear demonstration of effects on mortality, morbidity, psychological distress and other outcomes7,8.

Reliable research findings on the causes of elder mistreatment are more limited owing to a lack of studies using rigorous research designs. The literature to date has focused almost exclusively on proximal risk factors at the individual or dyadic level9,10. Factors with the strongest evidence include being female, poor mental or physical health, functional impairment, cognitive impairment, social isolation, low income, prior trauma or exposure to domestic violence, and a shared living situation1.

Some scholars, however, have suggested that the field should move beyond proximal causes to explain elder mistreatment. They propose that cultural and social-structural factors may directly promote elder mistreatment or provide an environment in which it is more likely to occur. Prominent among these explanations is the phenomenon of ageism. International and national organizations, advocacy groups and some researchers propose that ageism can increase the likelihood of elder mistreatment and neglect. For example, the World Health Organization11 includes as a likely cause of elder mistreatment “ageist stereotypes where older adults are depicted as frail, weak and dependent.”

In this Perspective, we explore the potential connection between ageism and elder mistreatment. Unlike certain other risk factors for elder mistreatment (for example, gender or functional decline), ageist attitudes are modifiable, with resulting potential to reduce risk. Despite the assertion that ageism is a causal factor, research evidence to support this connection is surprisingly weak. We begin with a discussion of the potential links between ageism and elder mistreatment and the limited empirical research on this topic. We then present a conceptual model to illustrate hypothetical pathways through which ageism may lead to elder mistreatment. We conclude with a research agenda to guide future empirical investigations of this issue.

For the purposes of this Perspective, we follow the World Health Organization in defining ageism as stereotyping, prejudice or discrimination toward people on the basis of age12. These characteristics represent three dimensions of ageism: cognitive (stereotypes), affective (prejudice) and behavioral (discrimination). Although people may be subjected to ageist attitudes from others, research also shows that such attitudes can be directed toward the self, with negative evaluations such as “I look so old” or “I’m no good anymore.” Further, most analysts propose that ageism can take place at several levels, including among individuals, through social networks and organizations such as workplaces, and on the societal and cultural level, for example, through policy and social norms13.

Connecting ageism and elder mistreatment

On what grounds can we hypothesize that ageism will increase the risk of elder mistreatment? Much of the treatment of this issue has taken place in theoretical discussions and macro-level policy analyses. The authors often begin from the standpoint that ageism is a major detrimental social problem that should be addressed and that elder mistreatment is one of a range of negative consequences of ageism14,15. It is proposed that addressing societal ageism improves factors like social isolation and exclusion, which in turn makes individuals less vulnerable to elder mistreatment16. Similarly, assigning a low value to older people is seen as leading to discriminatory treatment, which then leads to vulnerability to elder mistreatment through lack of resources and social capital17.

Thus, in this view, social norms and cultural values exist that promote negative attitudes toward older adults. These macro-level factors reduce awareness of elder mistreatment and allow policymakers to tolerate the existence of elder mistreatment and fail to pass measures to combat it. The legal system and financial institutions, as well, are seen as less responsive to elder mistreatment cases because of pervasive societal ageism18. Further, it is speculated that devaluing older people through ageism creates greater societal tolerance for elder mistreatment, thus increasing its likelihood in the population19. In sum, a number of analysts point to this possible connection, although a coherent theoretical framework linking ageism to elder mistreatment remains to be articulated.

The research evidence

Despite the plausibility of these arguments, there has been almost no empirical research linking ageism in any form to the incidence of elder mistreatment. It has been assumed that negative stereotypes and attitudes, as well as age-discriminatory policy, dramatically increase the risk for elder mistreatment; this assertion, however, remains highly speculative. One problem lies in the macro-level nature of the arguments for the role of ageism. Proponents typically assert that ageist beliefs and behaviors are ubiquitous; therefore, testing their impact on the incidence of elder mistreatment would be difficult because of the lack of variation. International comparative research has potential to shed light on this issue, exploring whether the extent of ageism across countries affects national elder mistreatment prevalence rates. No such studies, however, have been conducted.

Nevertheless, suggestive evidence for the potential role of ageism comes from two sources. First, there have been several studies that have attempted to examine the relationship between individually held ageist stereotypes and attitudes and a propensity toward committing or tolerating elder mistreatment. Second, research from other forms of interpersonal violence supports the hypothesis that attitudes may contribute to elder mistreatment behaviors.

Stereotypes of older people and elder mistreatment

It is possible that individuals with stronger ageist attitudes are more likely to engage in elder mistreatment. The hypothesized pathway is that devaluing older people reduces barriers or inhibitions to mistreating them. Conversely, empowering older people, demonstrating their value and highlighting their contributions are seen as a promising solution to addressing the ageism pathway toward elder mistreatment20. Research has revealed common stereotypes of older persons portraying them as being low in competence but high in warmth21. On the one hand, this pattern might insulate some older people from mistreatment, as the perception of low competence might lead to support from family and the community. However, the incompetence stereotype can also result in older people being rejected or ignored.

There is suggestive evidence from several studies to support the hypothesis that stereotypes foster elder mistreatment. Yon and colleagues22 found that ageist attitudes among university students were correlated with their likelihood of endorsing abusive behaviors toward older adults. Yechezkel and Ayalon23 examined how social workers identified abuse by an intimate partner. They found that participants were more likely to define actions toward a younger woman as abusive, in contrast to incidents involving an older woman. Ageist attitudes may affect the behavior of professionals, as well. Erlingsson et al.24 found that a diverse sample of social and legal service providers identified ageism as a contributing factor in the failure of health professionals to report elder mistreatment. Thus, an additional testable hypothesis relates to whether age-related stereotypes may affect professional awareness and assessment of potential victims of elder mistreatment.

Conspicuously missing from the research base are studies involving actual victims of elder mistreatment and perpetrators. Thus, empirical support for the ageism–elder mistreatment hypothesis is limited by study designs that have used hypothetical or vignette-based scenarios rather than real elder mistreatment cases, and understanding of elder mistreatment is therefore largely based on supposition. Slight evidence is available regarding the role of ageist stereotypes in the abuse of residents by staff in nursing homes. Studies have found that staff who report infantilizing older people are more likely to report neglectful and abusive actions25,26,27.

Thus, despite frequent assertions that ageism causes elder mistreatment, almost no empirical data exist to support this hypothesis, either in the community or in institutional settings. Therefore, determining whether individuals who hold ageist attitudes and stereotypes are more likely to commit elder mistreatment should be a high priority for future study.

Evidence from the domestic violence literature

Although the research evidence discussed in the preceding section provides little support for the relationship between ageism and elder mistreatment, parallels can be drawn from other domains of interpersonal violence. Studies of abusive behavior involving younger persons support a possible connection between social and cultural attitudes and propensity toward abusive behavior. For example, there is an established link between sexist attitudes and perpetration of intimate partner violence (IPV). A systematic review of risk factors for physical, psychological and sexual IPV found that hostility toward women was associated with justifying and perpetrating IPV28. In looking specifically at physical abuse perpetrated by men against women, a meta-analysis of 85 studies found traditional attitudes about women’s gender roles to be a moderate risk factor for abuse perpetration29.

A similar relationship between attitudes and abuse proclivity has also been demonstrated in the context of child maltreatment. There is considerable research demonstrating that acceptance of the use of physical violence against children is associated with increased use of corporal punishment30,31,32. In addition, a recent study found that perceived acceptability of both IPV and child maltreatment can be constructed more broadly as a general attitude of acceptance of family violence, rather than isolated attitudes toward specific forms of abuse33.

The relationship between individual attitudes and abusive behavior may also be moderated by country-wide normative attitudes toward corporal punishment and domestic violence. For example, in comparing the relationship between attitudes and use of physical discipline among mothers in Sweden and Canada, Durrant et al.34 found that Canadian mothers were more likely than Swedish mothers to have positive attitudes toward the use of physical punishment and more likely to use physical punishment. At the time, in Sweden, physical punishment was prohibited by law, whereas in Canada it was a legally sanctioned behavior. Similarly, in examining the relationship between domestic violence attitudes and corporal punishment attitudes across 25 countries, Lansford et al.35 found that individuals from countries with more normative views of domestic violence and corporal punishment had more positive personal attitudes toward these forms of violence and were more likely to use corporal punishment on their children.

Collectively, these findings demonstrate that attitudes have a significant role in understanding perpetration of interpersonal violence and emphasize the need for this relationship to be further explored in the context of elder mistreatment. No such relationship can be assumed in the absence of evidence, however, which at this point does not exist for elder mistreatment. Policymakers and social scientists should therefore be cautious in proposing policies or interventions based on the premise that reducing ageism will also lower elder mistreatment risk. A vigorous program of research on the connection is required at present; we offer guidance for such research in the following section.

Conceptual model linking ageism to elder mistreatment

On the basis of the review of literature examining the link between ageism and elder mistreatment, both at a conceptual level and based on suggestive empirical evidence, we propose a model (Fig. 2) to test hypothetical pathways through which ageism may lead to elder mistreatment. The model includes plausible (and modifiable) mediators and moderators that could be targeted as mechanisms of change in interventions designed to address the issue. As such, it provides a framework for future research on the topic.

Fig. 2: Conceptual model illustrating pathways through which ageism leads to elder mistreatment.
figure2

A conceptual model to guide future research on the relationship between ageism and elder mistreatment.

As presented in the model, several manifestations of ageism (exclusion/isolation, devaluation, depersonalization, infantilization, powerlessness and blame) are identified that serve to mediate the relationship between ageism and elder mistreatment. An ageist sociopolitical context disempowers older adults through exclusionary social practices that disproportionately isolate this population, which increases vulnerability to elder mistreatment. As a hallmark feature of ageism, older adults are perceived as having low value or as unworthy, which allows others to mistreat them with little accountability or inhibition. Similarly, widespread conventions that dehumanize or depersonalize older adults, for example, those living in institutional settings or with physical, functional and/or cognitive impairments, open the door to elder mistreatment.

Perhaps the most empirically supported pathway from ageism to elder mistreatment occurs through a process of older adult infantilization, which allows others to remove the dignity, respect and rights typically attached to adults in society. Infantilizing behaviors have been identified in both the ageism and elder mistreatment literatures36,37. Ageism contributes to deeply ingrained imbalanced age-based social processes and power structures that inherently privilege younger age groups and marginalize older adults as holding less power, which in turn increases vulnerability to elder mistreatment. Finally, a pervasive attitude of blame toward older adults, for example, as a burden to society or in failing to make an economic contribution, fosters a sense of resentment or justification for their devaluation.

Our review of the literature also revealed important elements that are included as moderators in the model (policy and social norms, intersection with sociocultural identities and systems of inequality, and internalization). The strength of the relationship between ageism and elder mistreatment depends on or is a function of the presence or magnitude of these moderating elements. As described above, country-specific social norms, values and policy predict tolerance and acceptance of family violence and influence related attitudes among individuals, as well as their propensity to enact violence-related behaviors. Similarly, policy and social norms related to ageism differ across defined contexts, for example, by geography or culture. The extent to which ageism is fixed within contextual policy and social norms will prescribe attitudes and behaviors among individuals and within institutions and, in turn, will influence the degree to which ageism and its manifestations contribute to vulnerability to elder mistreatment.

Using an intersectional lens, ageism does not operate in isolation from, but rather interacts with, other sociocultural processes that contribute to unequal social arrangements, such as processes related to gender, race/ethnicity, socioeconomic status, level of ability, sexual orientation and other systems of inequality. An older adult’s intersection with other social identities and systems of inequality will influence the level of ageism experienced and, in turn, the extent to which ageism contributes to elder mistreatment. For example, ageism and gender intersect to exacerbate negative stereotyping attached to physical aging among women compared to men, which may in turn elevate the risk of mistreatment among women.

Another important moderating factor in the model is the degree of internalized ageism at the level of individual older adults. Internalized ageism (or self-directed ageism) is viewed as a by-product of the ageism that operates in society. The model suggests that the relationship between societal ageism and elder mistreatment is moderated by the extent to which a given older adult has internalized societal ageism. Older adults who have internalized societal ageism and consequently carry negative views of themselves on the basis of their age (for example, viewing themselves as unworthy or undeserving) will be more likely to experience elder mistreatment and more likely to tolerate the abusive behavior without enacting protective measures. Alternatively, an older adult who has not internalized societal ageism (and in turn feels empowered as an older person) will be less likely to experience or tolerate elder mistreatment.

The proposed model can apply to older adults who experience ageism and elder mistreatment, as well as to those who exhibit ageist attitudes and in turn perpetrate elder mistreatment. Accordingly, the model promotes a framework for future research that collects data from both older adults themselves, including their experiences of ageism and elder mistreatment, and younger people, including their ageist attitudes and propensity to mistreat. Future investigators will need to address measurement issues as they test hypotheses based on this model. Operationalization of concepts such as infantilization and devaluation will require research to ensure accurate measurement. Over the past several decades, reliable and valid measures of elder mistreatment have been developed that are now widely used38, but continued development in this area is also necessary. Similarly, comparable measures of ageism are needed to facilitate international comparison39.

Agenda for future research

Despite a widespread belief that ageism is a causal factor in elder mistreatment, research does not exist at the present time to support this assertion. No studies have definitively linked ageism at the individual level to a higher risk of either committing or experiencing elder mistreatment. Further, the hypothesized relationship between elder mistreatment and macro-level cultural attitudes and ageist social norms has yet to be empirically demonstrated.

Support for this hypothesis, however, comes from the limited research we have reviewed on elder mistreatment as well as the evidence from studies of other domains of interpersonal violence. It is possible that the field suffers from publication bias, where statistically non-significant findings are unable to be published, which may contribute to the limited empirical evidence on the topic. On the basis of the conceptual model we have presented, we propose several priorities for future research.

Cross-national research

As discussed earlier, a core feature of the ageism–elder mistreatment hypothesis is that ageist norms, values, policies and laws at the macro-level create an environment that makes the mistreatment of individual older people more likely. To move from an advocacy position to testable hypotheses, identifying variation in both rates of societal ageism and elder mistreatment is necessary. Attempts have been made to rank countries on the basis of indicators of structural age discrimination40,41. Further, international data exist on ageist attitudes through the World Values Survey42. Although cross-national data from single studies do not exist on rates of elder mistreatment, numerous prevalence studies have been conducted at the national level6.

It therefore is possible to synthesize such data to examine whether higher levels of social-structural ageism are associated with national elder mistreatment prevalence rates. In such studies, it will be necessary to disentangle various factors that may influence both ageist attitudes and elder mistreatment prevalence across countries. For example, elder mistreatment prevalence is likely to be affected not only by dominant cultural norms but also by national laws protecting older persons. Such nuanced international comparative research could help pave the way for additional cross-sectional studies using individual-level data collection. A strength of such studies is their ability to take into account cultural variations in respect for older people, which may affect the prevalence of both ageist attitudes and elder mistreatment.

Longitudinal studies

To establish whether ageist attitudes, prejudices and stereotypes predict abusive behaviors, prospective longitudinal designs are necessary. For example, a longitudinal study could interview a large random sample of adults, using measures of ageism, in interviews at an initial time point. Follow-up interviews could assess self-reported elder mistreatment behaviors to determine whether higher baseline levels of ageism are related to future victimization of an older person. Surveys of older adults could also measure their experience of ageism (as perceived by the older adults as being experienced from others) and then follow up for victimization of elder mistreatment at later time points. It would then be possible to test the hypothesis that individuals who experience higher levels of perceived ageism are more likely to experience elder mistreatment. Other studies could explore whether self-directed ageist attitudes predict future elder mistreatment victimization.

Barriers exist, however, to such long-term longitudinal studies. First, such survey projects are very expensive if the sample is large enough to ensure sufficient power to detect enough elder mistreatment cases for analysis. Second, human subjects concerns may be raised, given that following respondents over time requires maintaining personal identification of individual respondents. Data privacy laws can make such studies challenging in some countries. Third, mandatory reporting laws in some countries can be a significant barrier, although mechanisms may exist that allow such research. For example, in the United States, it is possible to apply for a ‘Certificate of Confidentiality’ that protects individually identifiable data from compelled disclosure43. A promising strategy is to add items to existing longitudinal studies that have measured ageism in earlier waves. Later waves could include items about elder mistreatment victimization and perpetration.

The field could be enriched by testing alternative hypotheses to the connection between ageism and elder mistreatment. For example, personality or psychological characteristics of individuals might explain both ageism and elder mistreatment. Storey notes that antisocial personality traits and attitudes are associated with committing elder mistreatment44. Ageism may therefore be a component of a larger pattern of antisocial attitudes and resulting behaviors. Research could address this issue by measuring both ageist attitudes and other forms of negative attitudes in the same samples.

Research in long-term care facilities

The connection between markers of ageism such as infantilization or treating others as powerless and elder mistreatment can be investigated in nursing homes and other long-term care facilities. Initial research on this topic was promising. An early study27 conducted the most detailed survey completed to date of elder mistreatment by nursing home staff. Staff members’ ageist attitudes were measured by agreement with such items as “Nursing home patients are like children; they need discipline from time to time.” Staff who endorsed such attitudes were substantially more likely to have committed elder mistreatment. Despite these initial findings, this line of research has largely not been pursued. Barriers include ensuring confidentiality for staff and protecting participating nursing homes from reputational risk. Such studies are likely well worth the effort, as long-term care facilities can provide a ‘laboratory’ for both investigating the ageism–elder mistreatment link and intervention studies.

Intervention studies

Scientific intervention research is an area where cross-fertilization between the fields of ageism and elder mistreatment is likely to be the most productive. There is consensus in the field that intervention research on elder mistreatment is scarce and prior studies have generally used weak designs2. Thus, the development of evidence-based programs to prevent and treat elder mistreatment has been identified as the highest priority in the field45. Intervention studies in the field of ageism are both more plentiful and more promising; a recent meta-analysis found that anti-ageism interventions are potentially effective and can be delivered at low cost46. Interventions that promote education about aging and structured intergenerational contact with older people reduced ageist attitudes and stereotypes across various population groups.

Researchers should explore the degree to which interventions to reduce ageism also protect against elder mistreatment. Such studies, using rigorous randomized controlled designs, could be implemented with high-risk groups such as caregivers to persons with dementia and long-term care staff. Measurable outcomes include changes in self-reported tolerance for elder mistreatment, as well as elder mistreatment actions taken. Unlike some other risk factors for elder mistreatment (for example, gender), ageism is potentially modifiable. If such programs are effective, they would provide experimental evidence currently lacking for the link between ageism and elder mistreatment.

Conclusion

Ageism is commonly positioned as an important risk factor for elder mistreatment, but there is very little empirical evidence to support this relationship. We have proposed a conceptual model to help understand plausible pathways whereby ageism leads to elder mistreatment, which can be used as a framework for future research. More robust research is required to confirm or disconfirm the link between ageism and elder mistreatment, which if demonstrated could lead to development of interventions that target key mechanisms of change. High priority should be given to cross-national and longitudinal designs, studies in long-term care facilities and intervention studies. Such a vigorous program of research will advance understanding about the intersection of the pressing and growing problems of ageism and elder mistreatment.

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Acknowledgements

We thank D. Hancock for helpful comments on this article. K.P. acknowledges support from an Edward R. Roybal Center Grant from the National Institute on Aging (P30AG022845). D.B. acknowledges support from the National Institute on Aging (R01AG060080-0).

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K.P. led manuscript writing and collaborated on manuscript conceptualization, editing and revisions; D.B. collaborated on manuscript conceptualization, writing, editing and revisions; and A.M. collaborated on manuscript conceptualization, writing, editing and revisions.

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Correspondence to Karl Pillemer.

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Peer review information Nature Aging thanks Briony Dow, Gill Livingston and the other, anonymous, reviewer(s) for their contribution to the peer review of this work.

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Pillemer, K., Burnes, D. & MacNeil, A. Investigating the connection between ageism and elder mistreatment. Nat Aging 1, 159–164 (2021). https://doi.org/10.1038/s43587-021-00032-8

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