Mistreatment of Older Persons: Federal Policy Definition - Explanatory Document

3.1 Mistreatment

There is no unique way to refer to mistreatment of older persons. Since the concept was introduced in the scientific literature at the start of the 1970s as “dirty work with old folks” (Stannard, 1973) and “granny battering” (Burnston, 1975), it came to be known under many names, mainly elder abuse, mistreatment and maltreatment (McDonald, 2007). Used as synonyms of each other, maltreatment is sometimes understood as a subset of mistreatment used to refer to harsher physical manifestations of the issue (Merriam-Webster, s.d.; Rubina 2017).

Internationally, elder abuse has been the most used of the three (Beaulieu & St-Martin, 2022). However, mistreatment has seen its use increase rapidly over the years and has found its place in some prominent organizations in Canada. The Canada Research Chair on Older Adult Mistreatment prevention in Toronto and the Research Chair on Mistreatment of Older Adults in Sherbrooke being two notable examples. As for maltreatment, it is rarely associated or linked with abuse of older persons, being often associated with child abuse. Different terms seem to be naturally adopted depending on the affected group, noting that there is no clear rationale for this in the literature. Still, when including both older persons and children in searches, the term mistreatment comes up more often for older persons.

For this definition, “mistreatment” was chosen to refer to the issue as it was found to be more inclusive. Indeed, it implicitly includes violence and neglect which is not the case for abuse, and it is not restricted to harsh physical events. Moreover, there are several advantages to this term. In particular, it is congruent with the evolution of concepts surrounding the issue (id est: well-treatment). “Abuse” also has a strong association with the legal world. It sometimes brings forth ideas of assault, robbery, extortion or sexual assault, which are all crimes under the Criminal Code. The use of “mistreatment” can thus help avoid the reluctance that some people may have when the term used to refer to the issue has a legal connotation. This is especially true when the perpetrator is a family member as there may be a fear of implicating the law in what is perceived to be a familial matter (Beaulieu & St-Martin, 2022).

3.2 Older persons

The use of “older persons” to refer to those who are affected by mistreatment conveys a sense of personhood. It is the term used by the United Nations to designate the universal day of older persons since 1990 (UN, 2022). It highlights that being older is simply an added characteristic to the fact of being a person. Moreover, the term older is flexible since it is not generally associated with a restrictive age or condition. As such, the expression is both respectful and inclusive of people who may have a different course of aging. The use of “older persons” rather than the more common “older people” is deliberate. It aims to show that those who are affected by mistreatment are all different individuals and that they do not belong to a homogeneous group (people). By using this term, it makes it clear that any person can experience mistreatment, regardless of culture, sexes, sexual orientations, genders, gender identities, gender expressions and perceived genders, beliefs, languages, ethno-cultural background, physical and cognitive capacity, etcetera (Beaulieu & St-Martin, 2022).

Other terms that are often used when referring to those affected by mistreatment were also considered but were rejected for varying reasons. “Senior”, which once was a popular term, is now interpreted by many as being particularly restrictive because of its association with the age of retirement and pensions. Moreover, senior is not a globally recognised term. “Elder” which remains in use through the expression “elder abuse” was avoided to be respectful of the Indigenous peoples for whom the term does not refer to age, but rather to a person who stands out as a model for their peers because of their spirituality, wisdom, values, teachings, and contribution to the community (Beaulieu & St-Martin, 2022). While there was no real opposition to the use of “older adults”, the governmental representatives as well as the researchers that were consulted had a slight preference for “persons”. It also happens to be the term used by the United Nations and is closer to the term “people” which is used by the World Health Organisation (WHO, 2022).

4.1 Number of occurrences: “Single or repeated”

The mention of a “single” or “repeated” event indicates that even one occurrence of an inappropriate act, word or attitude, or lack of appropriate action is enough to consider that there was mistreatment if the other criteria are present.

However, this notion calls for caution. Taking into consideration any single situation as potential mistreatment can obscure the difference between a simple conflict and actual mistreatment (Beaulieu & St-Martin, 2022). In this regard, it is important to remember that occasional conflicts, defined as “active disagreements between people with opposing opinions or principles” (Cambridge Dictionary, s.d.) are normal parts of a relationship, even if they can sometimes get heated. In such cases, intensity, repetition and usual patterns should be considered.

4.2 Perpetrators: “Person, group, community or organization”

The definition introduces the idea that “a person, group, community or an organization” can be mistreating rather than being restricted to an individual as is often the case. This addition aims to fight against the perception that mistreatment is only an inter-individual or intra-familial issue and opens the door to a broader vision and better accountability.

This is particularly useful for targeting the changes that need to be made to resolve events of mistreatment. For example, in an institutional setting, the interventions required if a service provider does not meet the needs of an older person because they are unwilling to do so are different from if the organization does not provide the material or human resources needed to do so.

• By person, the definition refers to individuals who are in a relationship with the older person. It can be relatives, family members, life partners, service providers, friends, neighbours, etcetera
• By group, the definition refers to groups of individuals linked by common interests, organization, culture or geographical location. It can be an association that the older person frequents, a dance group, etcetera
• By a community, the definition refers to a set of interdependent individuals who influence each other and perceive themselves as members of the same social identity” (Free translation, Vallerand, 1993, p. 783-784). It can be a faith community, etcetera
• By organization, the definition refers to situations that result from the practices and management methods of an organization or an institution. It can be a hospital, a long-term care facility, a company, a banking institution, etcetera

4.3 Link between the older person and the perpetrator: “a relationship where there is an expectation of trust”

Mistreatment of older persons is often framed as occurring within a relationship of trust. This indicates that strangers cannot be perpetrators and leads to the exclusion of events such as theft and fraud by an unknown entity. This formulation is sometimes criticized, as in some cases it can be used to imply that older persons are responsible for the mistreatment they experience by giving their trust to someone who was undeserving (Beaulieu & St-Martin, 2022).

The use of “relationship where there is an expectation of trust” in this definition aims to counter this criticism and to take the blame away from older persons. The added clarification indicates that mistreatment occurs in relationships where it would be normal to expect trust. For instance, trust would be expected from a relationship with a service provider, a caregiver, a banking establishment, a religious community, a long-term care facility, etcetera.

The majority of experts agree on the fact that the notions of relationships and trust are very important to a definition to avoid ending up with all forms of victimization covered by it. However, there are debates about whether these concepts should be framed in such a way as to allow for the inclusion of frauds and scams involving persons assuming a false identity or title that induces trust. For example, pretending to be a grandchild, a government official, a computer technician, etcetera. The use of “expectation of trust” keeps the door open to including these kinds of events at some point, but in its current form the definition would not include them (Beaulieu & St-Martin, 2022).

4.4 Manifestation of the issue: “act, word, attitude, or lack of appropriate action”

Mistreatment is always characterized by a certain form of violence often described as “actions”. This term is generally understood to encompass physical, verbal or attitudinal manifestations of mistreatment, although this is not always made explicit (Beaulieu & St-Martin, 2022). As such, when used in the context of mistreatment, the notion of violence goes beyond harming someone in a physical way. This is consistent with the WHO definition that describes violence as:

"The intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation" (WHO, 2002, p.5.)

Moreover, “in psychology, an attitude refers to a set of emotions, beliefs, and behaviours toward a particular object, person, thing, or event” (Cherry, 2023, n.p.) Attitudes can be either positive, neutral or negative. They are influenced by experiences, social roles and norms, classical and operant conditioning and, the observation of people in environment. This concept is broader than “acts or words” (as stated in the definition of mistreatment that is proposed), adds nuances to the definition and expands the notion of violence. The following scenario shows why this addition can be important in certain contexts:

A staff member in a residential facility is fulfilling the duties of his job adequately, follows his charts and provides proper care and medication to the residents. All the while, he shows a complete lack of interest for the older persons around him. He does not engage outside of the required task, never chats with the residents and is comfortable talking with other staff member as if there was no one around.

In this example, what is described could hardly be considered as an act or a word, but it still reflects an attitude by a person, group or organization that can lead to negative consequences for the older persons. To this, the idea of omissions or lack of appropriate action (often called neglect) is often added. As such, the approach of categorizing the manifestations under the forms of violence or neglect was adopted. Violence is used to refer to active mistreatment such as actions, words or attitudes, while neglect refers to passive mistreatment or a lack of appropriate action (Beaulieu & St-Martin, 2022). That is to say that not providing care to an older person, ignoring them, or not meeting their needs when required can be mistreatment.

This way of presenting the manifestations of mistreatment makes it explicit that it can be expressed in several ways and that it is possible to be mistreating without having acted or spoken against an older person. It also allows for a more in depth look at the different manifestations of neglect as it can be examined through a different lens for each type of mistreatment, as opposed to definitions where neglect is a type amongst the others.

4.5 Impacts of mistreatment: “causes or risks causing negative consequences”

The majority of definitions deal broadly with the notion of consequences, mentioning that mistreatment causes harm or distress, but some definitions seek to be more precise, detailing types of consequences that are similar to types of mistreatment (Beaulieu & St-Martin, 2022). Neither of these approaches were used for the definition. On one hand, the notion of harm and distress would be restrictive as it suggests that an event that did not reach the threshold for causing harm or distress could not be mistreatment. In contrast, mentioning every type of consequences would lead to a bloated definition. As such, the simple idea of “negative consequences” is used to implicitly describe any physical, psychological, social and financial consequences that could affect the health, security and well-being of older persons (WHO, 2022). Each of these four categories of consequences are often documented in population-based studies on mistreatment without being explicitly quoted in definitions (Gingras, 2020). Table 1 presents some examples of the possible consequences of mistreatment.

Source: Beaulieu et al., 2022

Often paired with the concept of consequences is the notion of risk which indicates that mistreatment can occur even if negative consequences have not yet materialized. Although this introduces subjectivity to the definition, it is essential to avoid excluding situations that involve older persons living in vulnerable situations. Notably those with neurocognitive disorders, quadriplegia or who are unconscious, as they may not directly experience the consequences of mistreatment.

4.6 Intent: “Intentional or unintentional events”

Although the definition does not include the notion of intent, it is implied that there may be unintentional mistreatment and that those event(s) also need attention. Socially, people tend to see only intentional events as mistreatment and see unintentional events as accidents or blunders. Yet, even if an event is unintentional, it can still be unacceptable and have significant consequences for the person experiencing it (Beaulieu & St-Martin, 2022).

5.1 Psychological mistreatment

Psychological mistreatment is characterized by acts, words, attitudes or lack of appropriate actions that cause or risk causing negative consequences on the psychological, emotional and moral integrity, health, security and well-being of an older person.

• In the form of violence it can manifest as (but is not limited to) emotional blackmail, manipulation, humiliation, insults, infantilization, belittlement, verbal and non-verbal threats, disempowerment, excessive, comments that are xenophobic, ableist, sexist, homophobic, biphobic, transphobic, invalidating the belief of the person, mocking and criticizing spiritual practices (example given: prayers), accusing someone of sorcery, using someone’s spiritual beliefs to deceive them or lead them to do something they would not otherwise do, breaking a spiritual symbol, etcetera
• In the form of neglect it can manifest as (but is not limited to) rejection, social isolation, abandonment, disinterest, insensitivity, not considering the spiritual needs of the person, not providing conditions that are favorable to the exercise of one's spirituality, etcetera

5.2 Physical mistreatment

Physical mistreatment is characterized by acts or lack of appropriate actions that cause or risk causing negative consequences on the physical integrity, health, security and well-being of an older person.

• In the form of violence it can manifest as (but is not limited to) shoving, brutalizing, hitting, burning, force-feeding, inadequate medication administration, inappropriate use of restraints (physical or pharmacological), etcetera
• In the form of neglect it can manifest as (but is not limited to) failure to provide a reasonable level of comfort and safety, failure to provide assistance with eating, grooming, hygiene or taking medication when the older person is in a situation of dependency, abandonment, etcetera

5.3 Sexual mistreatment

Sexual mistreatment is characterized by acts, words or attitudes that disregard consent, are unwanted, coerced or forced, or by lack of appropriate actions that cause or risk causing negative consequences on the sexual integrity, health, security and well-being of an older person.

• In the form of violence it can manifest as (but is not limited to) degrading jokes or remarks of a sexual nature, sexual advances, contacts or behaviors known or that reasonably ought to be known unwelcome, sexual assault, etcetera
• In the form of neglect it can manifest as (but is not limited to) failure to provide privacy, systematically treating older persons as having no sexual attraction to others, or a lack of desire to have sex and/or preventing them from expressing their sexuality, etcetera

5.4 Material or financial mistreatment

Material or financial mistreatment is characterized by acts, words, attitudes or lack of appropriate actions that cause or risk causing negative consequences on the financial integrity, health, security and well-being of an older person or their property.

• In the form of violence it can manifest as (but is not limited to) pressure to change a will, banking transactions without the person’s consent (use of a debit card, online banking, etcetera), misappropriation of money or assets, excessive price charged for services provided, forced or concealed contractual or insurance transaction, identity theft, signature of a lease under pressure, etcetera
• In the form of neglect it can manifest as (but is not limited to) failure to manage the person’s assets in his or her best interest or to provide the necessary goods and/or services as required, failure to assess the person’s abilities, understanding and financial literacy, etcetera

6.1 Chronological age: When is someone “old”?

Chronological age, which is often included alongside mentions of “older persons” to make clear who this term refers to, is absent from this definition. It was not included to ensure the definition would remain valid even if the age at which someone is considered “old” was to change. Moreover, experts often contest the use of chronological age to qualify advancement into older age, noting that physical, psychological and social indicators are more appropriate (Morgan & Konkel., 2016).

Yet, it is recognized that chronological age is the simplest method to define admissibility criteria to programmes or services. In Canada, the age of 65 is often used to qualify someone as an older person, since it is the age at which most people become eligible for the Old Age Security pension. Despite that, it is common for people who have experienced certain physical, psychological or cognitive health issues or gone through adverse life experience (incarceration, homelessness, violence, etcetera) to show advanced sign of aging and present characteristics associated with older people at the age of 60, 55 or even younger.

6.2 Diversity and intersectionality: Who experiences mistreatment?

“Aging does not mean breaking with one's past to enter a separate category of the population. On the contrary, aging is most often part of the continuity of an existence marked by one's individuality and by one's belonging to different groups” (Wallach, 2012, p.5).

As such, older persons represent a diverse part of the population. One with different sexes, sexual orientations, genders, gender identities, gender expressions and perceived genders, beliefs, languages, ethno-cultural background, physical and cognitive capacities, and lived experience. This diversity, while something worth celebrating can create unique challenges for some older persons. Especially those who belong to groups that experience marginalization or discrimination (example given: Indigenous Peoples, members of 2SLGBTQI+ communities, racialized communities, ethno-cultural groups, new immigrants, and persons with disabilities) (Walsh et al., 2010; Owen-Williams, 2012; Haukioja, 2016; Cooper et al., 2020; Gutman et al., 2020; Penhale, 2020; Beaulieu et al., 2022). This diversity is also present in the various settings where older persons live (home, multi-generational home settings, residential facilities, rural and remote areas, and prisons) (Beaulieu & St-Martin, 2022). Individual and environmental factors such as language barriers, maladapted services, economic disparities, lack of social support and experiences of discrimination to name but a few, can all increase the risk of experiencing mistreatment or make seeking help in cases of mistreatment more complex. For example, for Indigenous Peoples, there is a need to consider the legacy of the residential school system, as well as their geographic, economic, and social contexts.

The fight against mistreatment therefore implies taking into account the role of structural factors in the difficulties encountered by older persons and the intersection of their multiple characteristics and social positions (Wallach, 2012). As such, adopting an intersectional approach to understand and counter mistreatment of older persons calls for an exploration of “the interactions with other social factors such as gender, sex, race, ethnicity, Indigenous identity, disability, sexual orientation, gender identity, religion, social status, place of origin and immigration status” (United Nations Human Rights Office of the High Commissioner, 2023, n.p.).

6.3 Context: What surrounds mistreatment?

Mistreatment of older persons is a complex issue that is influenced by a variety of individual and environmental factors. They can be linked to family history, neighborly relations, medical condition, socio-economic status, ethnicity, cultural background, sexes, sexual orientations, genders, gender identities, gender expressions and perceived genders, and more. This is what colors the context in which mistreatment occurs and makes each mistreatment event different (Lindenberg & al, 2013).

Considering these specific components and their impacts is crucial for all actors involved in addressing mistreatment. However, it is important to note that different people may have different interpretations of an event and its context. As such, to find a proper solution and the best actions to undertake, open communication is required. This not only means exchanging with the other actors addressing the situation but also listening to the perspectives, needs, preferences and wishes of the older persons.

6.4 Ageism: A global issue linked to mistreatment

Ageism is a multifaceted issue that operates on both the individual and the societal level. Defined as “the stereotypes (how we think), prejudice (how we feel) and discrimination (how we act) towards others or oneself based on age” (WHO, 2021, p.2), it can have tangible effects on various aspects of the personal and social life of older persons. Moreover, it can act as a conscious or unconscious motive or legitimizing factor for mistreatment. As such, recognizing ageism and its impacts and maintaining efforts to counter ageism is essential in the fight against mistreatment. In this regard, the WHO has identified combating ageism as the number one global priority to tackle abuse of older persons for the Decade of Healthy Ageing (2021-2030) (WHO, 2022a).

6.5 Rights violation: A transversal issue found in every type of mistreatment

It is important to recognize that older persons have the same rights as any other adult, and that these rights are susceptible to be infringed upon in all events of mistreatment. Addressing mistreatment requires a comprehensive approach that includes promoting and protecting the human rights of older persons. This involves not only addressing the immediate harm caused by mistreatment, but also addressing the underlying structural factors that contribute to these violations, such as ageism, discrimination, and inequality (United Nations, s.d.; Chaire de recherche sur la maltraitance envers les personnes aînées et al., 2022).

6.6 Interpersonal violence at all ages and in all contexts

Mistreatment can be experienced at various ages in life (from birth to death) and in various settings (home, school, work, institutions, prisons, etcetera). Depending on the population of interest, it is clear that the field of study, the advocacy and the interventions take on slightly different forms and are designated differently. Thus, we are exposed to concepts such as child abuse or maltreatment, intimate partner violence, mistreatment of older persons, resident-to-resident abuse, violence in the workplace, bullying, etcetera. All these fields share a concern for interpersonal violence and some include mistreatment committed within groups, communities and even organizations. Also, some of these fields, notably those dealing with children and older persons, explicitly include neglect.

Dialogue between all the fields that take an interest in interpersonal violence is essential as they often interact, intersect or overlap in part or in whole with one another. A central element to opening this dialogue is the adoption of a life course approach which promotes the documentation of the effects of mistreatment at any age, on both the short and long term. Several studies adopting this approach have already shown a strong correlation between experiencing mistreatment as an older person and having experienced mistreatment as a child (McDonald & Thomas, 2013).