The United Nations Decade for Healthy Ageing 2021–2030 (hereafter, the Decade) aims, through 10 years of concerted action, to improve the lives of older people, their families and the communities in which they live1. All people are entitled to age with dignity, honor and respect, including being free from violence, abuse and neglect. Although abuse of older people was first recognized 50 years ago and began to register on the global agenda 25 years ago, the issue has not received the prominence it deserves. The Decade offers a unique opportunity to elevate this issue globally.

To this end, the WHO convened a group of 50 international experts and stakeholders (academics, policymakers and funders) in the field to conduct a priority setting exercise to help to tackle abuse of older people in a coordinated and strategic way2. The development of effective interventions emerged as one of the top priorities, as no interventions have been proven to prevent or reduce abuse of older people in high-quality experimental studies. Without effective — and cost-effective — interventions, it is unlikely that addressing abuse of older people will be prioritized by governments, international and civil society organizations, or by donors. To address this situation, we propose to create an ‘intervention accelerator’. This new entity would consist of an international research–practice network, led by the WHO, which would work to speed up the development and evaluation of effective interventions for abuse of older people.

Abuse of older people is a serious and growing problem

Abuse of older people — also known as ‘elder abuse’ — is defined by the WHO as a single or repeated act or lack of appropriate action, occurring within any relationship in which there is an expectation of trust, that causes harm or distress to an older person. It constitutes a violation of human rights and includes physical, sexual, psychological and emotional abuse; financial and material abuse; abandonment; neglect; and serious loss of dignity and respect3. Abuse can occur anywhere, including in the community and institutional settings.

Abuse of older people is a widespread and growing problem. Globally, the WHO estimates that 1 in 6 people aged 60 and older experience some form of abuse in the community every year4. Even if its prevalence remains constant, the number of older people experiencing abuse is predicted to increase due to rapid population aging. By 2050, the global population of people aged 60 years or older will more than double, from 1 billion in 2019 to about 2.1 billion1.

Abuse of older people has serious health, social and economic consequences for individuals, including physical injuries, premature mortality, emotional and psychological distress, mental health problems, decline in cognitive functioning, financial devastation and placement in nursing homes. Abuse of older people also causes distress in families by undermining solidarity and trust, and results in higher social costs through increased risk of institutionalization, hospitalization, emergency service, morbidity and mortality5,6.

Despite the scale and severity of abuse of older people, the global response to abuse of older people remains weak, and the issue has received limited resources and attention from international and national organizations7. The Global Status Report on Violence Prevention 2014, which assessed the measures that countries were taking to address interpersonal violence, found that abuse of older people was addressed the least frequently8. International and civil society organizations have all sought to address the issue of abuse of older people, but their responses have often been fragmented, sporadic and lacking in sustained funding7. Recent systematic reviews of interventions are unanimous: there are currently no interventions to prevent and respond to abuse of older people with demonstrated efficacy in high-quality evaluations9.

The Decade offers a unique opportunity to tackle abuse of older people in a concerted, sustained, coordinated and better-resourced way. The Decade is a global collaboration among governments, civil society, international agencies, professionals, academia, media and the private sector to improve the lives of older people, their families and significant others and the communities in which they live. The Decade recognizes abuse of older people as an important issue that cuts across its four main action areas — ageism, age-friendly environments, integrated care and primary health services, and long-term care1.

Developing effective interventions is a top priority

As a first strategic step toward addressing abuse of older people, the WHO and partners engaged in a priority setting exercise2. First, a long list of challenges facing the field was compiled on the basis of a study of factors that account for the low global priority of abuse of older people7, gaps identified on an evidence and gap map10, and an overview of recent systematic reviews. Second, 50 experts and stakeholders were asked to rank the long list of challenges and participate in an online meeting, which resulted in the selection of the following five priorities for tackling abuse of older people within the Decade:

  1. 1.

    Combating ageism (a major reason that the issue receives inadequate attention);

  2. 2.

    Generating more and better data on prevalence of abuse of older people, particularly in low- and middle-income countries, and on risk and protective factors;

  3. 3.

    Developing and scaling up effective and cost-effective interventions;

  4. 4.

    Making an investment case for addressing abuse of older people; and

  5. 5.

    Raising funds for the field2.

Despite decades of research, the field has failed to develop effective interventions across community and institutional settings9. Developing and testing in high-quality evaluations interventions that are both effective and cost-effective is critical. We know from other fields that most interventions implemented do not work and end up wasting scarce resources11. There is also a risk that interventions have harmful effects or unintended negative consequences. Further, the availability of cost-effective solutions is a key criterion for prioritizing issues in national health strategies. Without effective solutions, the field of abuse of older people will probably continue to struggle to mobilize resources, and the opportunity costs of intervening will continue to appear prohibitive to decision- and policymakers.

Possible reasons for the current weak evidence base include limited research interest from fields that typically develop interventions (such as public health); inherent difficulties in creating interventions for vulnerable populations, some of whom are unable to consent to participate in research owing to cognitive impairment; lack of validated outcome measures; failure to move promising practices into rigorous testing for effectiveness; the complex nature of many interventions, which often require the involvement of several sectors (such as healthcare, education, social and criminal justice); and the lack of priority of the issue and associated funding constraints.

However, there is good reason to believe these challenges can be overcome and effective interventions can be developed. Such progress has been accomplished in other areas of interpersonal violence that face similar challenges, such as the prevention of violence against children (INSPIRE) and violence against women (RESPECT). Moreover, there is already a large body of promising work on which to build. A mapping of the evidence currently under way and yet to be published has identified some 50 systematic reviews of interventions to prevent, detect and respond to abuse of older people, which include over 700 primary studies10. Yet, despite the existence of so many reviews and primary studies, there are no high-quality evaluations — which adhere to accepted standards in the field of evaluation research, such as the Cochrane Collaboration risk of bias tools for randomized and non-randomized intervention — that demonstrate that an intervention works. This is an opportunity for the global public-health community to improve the quality of research in the field.

Intervention studies using minimally acceptable methods have generally found equivocal or negative results12. For instance, an evaluation of an intervention targeting family caregivers in the UK, using a randomized controlled design, found it had no effect13. Interventions that aim to support and educate victims of abuse appear to lead to more reporting of abuse. However, it is unclear whether the higher reporting means more abuse is occurring or whether there is a greater willingness to report the abuse when it occurs14.

Several reviews have, however, identified promising interventions, even if evaluations were of lower quality. These include caregiver interventions that provide services to relieve the burden of caregiving, such as housekeeping and meal preparation, respite care, education, support groups and day care. Another promising intervention is multidisciplinary teams that coordinate the many services (for example, criminal justice, mental health, healthcare, long-term care and so on) that are required for effective prevention of abuse of older people12. Education-based interventions, for primary healthcare service providers for instance, have also shown some promise9.

An intervention accelerator for effective interventions by 2030

Given the magnitude and severity of abuse of older people, the lack of interventions proven to work, and the global urgency to remedy this problem, we propose an ‘intervention accelerator’ project. It will be made up of an international research-to-practice network led by the WHO aiming to speed up the development of effective interventions, and create a portfolio of cost-effective interventions to prevent and respond to abuse of older people in community and institutional settings within low-, middle- and high-income countries. The network will be composed of two concentric groups: first, an approximately ten-person steering committee (made up of several authors of this Comment and a few others), which will drive this project forward; and, second, a wider group made up of teams of developers, evaluators and implementers of promising interventions from around the world, who will be selected and invited to participate.

The intervention accelerator will generate innovative ideas, test and evaluate widespread best practices, and promote rigorous evaluations of promising interventions to reduce or prevent abuse. For instance, in relation to a promising intervention such as a caregiver intervention previously tested in low-quality evaluations, the accelerator would proceed as follows: (1) refine and develop the intervention further if necessary, based on current knowledge of risk and protective factors and theories of change; (2) pilot test the intervention in a small non-randomized evaluation in a single site (either a low-, middle- or high-income country, adapting to the local context as required), and then refine it further; (3) evaluate the intervention in a randomized controlled trial in the same site, refining it further on the basis of the findings of the trial; and (4) and then test it in a multisite trial, including a mixture of low-, middle- and high-income countries, adapting it as required.

During the eight remaining years of the Decade, drawing on the experience of similar initiatives in fields such as childhood obesity prevention15, health conditions of the poorest populations (, child and adolescent health (, and the prevention of violence against children (INSPIRE) and women (RESPECT), the intervention accelerator will proceed in four steps (Fig. 1). The WHO will fund the first (screen and create database), second (create and maintain network), and a part of the third step (develop and test interventions), and further funds will be raised for the remainder of the third and the fourth steps (intervention portfolio).

Fig. 1: Intervention accelerator for abuse of older people.
figure 1

Outline of steps to develop the intervention accelerator.

It is high time that abuse of older people received the attention it requires. Effective solutions are urgently needed to stop older people from being abused. A concerted, adequately resourced and sustained international effort, drawing on the best expertise in the field of abuse of older people and the latest scientific guidance on intervention development could put an end to this state of affairs. It is time, we believe, for an intensive and unstinting international effort to develop interventions to prevent abuse of older people. We hypothesize that before the Decade is complete, the proposed intervention accelerator will succeed in producing a portfolio of cost-effective intervention approaches that are ready to be scaled up around the world, which will substantially reduce all forms of abuse of older people globally.