Preventing and responding to the mistreatment of older adults: Gaps and challenges exposed during the pandemic

Ageism

Ageism against older adults was highlighted throughout the pandemic (FPT, 2022; Fraser and others, 2020; Perks, 2021; Sutter and others, 2022). According to the World Health Organization, ageism is defined as:

“stereotypes (how we think), prejudice (how we feel) and discrimination (how we act) toward others or oneself based on age”

Poor quality care and disproportionate rates of COVID-19-related deaths in long-term care settings highlighted a lack of attention and resources in addressing older adult needs. In the community, measures intended as protection resulted in older adults experiencing heightened levels of social exclusion and isolation in their homes without equivalent measures to provide connection (Rouleau, 2022). The proliferation of and reliance on internet-based platforms to facilitate such social connections carried ageist assumptions. It required a certain level of digital literacy and functional and cognitive capacity that some older adults did not have. In turn, it led to difficulties accessing informal and formal social supports. Use of such internet-based technology became an accepted norm throughout the pandemic, without acknowledging a digital divide across age groups or addressing issues of digital literacy and access to technology among older adults.

Ageist discourses related to older adults as burdens to society were magnified during the pandemic along with resentment toward older adults. These included views that older adults should sacrifice themselves for the good of younger people (Barrett and others, 2021; FPT, 2022; Lagacé, and others, 2022). Older adults experienced intimidating looks, as well as derogatory or aggressive comments (Thivierge and Guay, 2020). Healthcare protocols that prioritized younger age groups and served to devalue the health and well-being of older adults emerged as institutionally based ageist practices throughout the pandemic (Ontario Human Rights Commission, 2020). There is a need to develop care models and support services based around the needs of older people (Abdi and others, 2019). Since long-term care settings across Canada are underfunded, they were not ready to face the pandemic (Meloche, 2022).

Using an intersectional lens, ageism did not operate in isolation from, but rather interacted with, other socio-cultural processes that contribute to unequal social arrangements. That is, processes related to:

• gender
• race or ethnicity
• socio-economic status
• level of ability
• sexual orientation
• other systems of inequality

An older adult’s intersection with other social identities and systems of inequality influenced the level of ageism experienced and, in turn, the extent to which ageism contributed to MOA (Pillemer and others, 2021).

Overall, ageism throughout the pandemic increased vulnerability to and provided justification for MOA and represents a critical target for primary prevention efforts (CSQ-FSQ, 2020; Pillemer, Burnes, and MacNeil, 2020).

Informal caregiver burden and availability

Older adults living with day-to-day functional impairments or physical health issues requiring daily care and assistance are disproportionately affected by MOA (Burnes and others, 2021b; Burnes and others, 2022b). Therefore, mechanisms to support informal caregivers providing such care to older adults represent an important form of primary MOA prevention.

Informal caregivers (family, friends) providing day-to-day care for older adults experienced elevated levels of stress and burden throughout the pandemic (Liu er al., 2021; Makaroun and others, 2021). Supplemental caregivers (for example, other informal caregivers, formal homecare providers) who would normally be available to help primary caregivers with care responsibilities were less available or unable to access the home (Chin-Tung and others, 2021). This placed a greater load on individual primary caregivers. Informal caregivers did not have access to the same levels of respite support or other forms of support (for example, support groups) to alleviate stress and burden during the pandemic. Some of them were also dealing with competing demands, such as supporting school-aged children doing online learning at home or increased levels of financial hardship (Makaroun and others, 2020). Similarly, community programs for older adult care recipients that would normally provide a break for caregivers were shut down or restricted at various times throughout the pandemic (Poulin and others, 2021). In sum, informal caregivers did not have access to the same resources or sources of support and respite throughout the pandemic which, in turn, resulted in elevated levels of stress and burden, which can translate into a higher propensity to mistreat.

Homecare availability

Related to the challenges experienced by informal caregivers was the availability of formal homecare supports throughout the pandemic. The number of homecare assessments, for example, declined substantially by 44% in April 2020. It remained lowered over subsequent months of reporting (Canadian Institute for Health Information, 2021). The availability of formal homecare to meet the day-to-day needs of older adults living with functional, cognitive, or physical impairments is an important form of primary MOA prevention. Without homecare support, basic care needs are unmet and older adults are put in a vulnerable position to depend on others. Throughout the pandemic, some homecare workers were unable to continue caring for older adults due to illness, agency policy, or social distancing restrictions. Other workers were unwilling to provide care due to fear of contracting or spreading COVID-19, either in traveling to or from the older adult’s home or in providing care. In some scenarios, families chose to cease homecare to reduce potential virus exposure. Reduced homecare also placed greater strain on informal caregivers (as mentioned above), who were already suffering from increased levels of burden and stress (Liu and others, 2021).

Social isolation

Older adults in particular experienced increased levels of social isolation throughout the pandemic. Social isolation represents a strong risk factor for MOA (Burnes and others, 2022a; FPT, 2021; Perks, 2021). With heightened vulnerability to the negative health consequences of COVID-19, older adults were encouraged and socialized throughout the pandemic to remain cautiously homebound, above and beyond the social distancing requirements and widespread stay-at-home mandates affecting the entire population. As a result, older adults were disconnected from informal and formal social support structures in their lives that represented important sources of protection against MOA (Han and Mosqueda, 2021). Interaction with peers and participation in activities outside of the home are important mechanisms to build social capital, which buffers against social isolation and mistreatment. Specifically, many older adults were socially disconnected (or experienced substantially lower levels of connection) from:

• family and friends
• community activities (for example, senior centres, day programs, faith-based gatherings)
• health and social services that were shut down or restricted

Older adults also experienced barriers to leaving the home to access important supplies, such as food and medications (Liu and others, 2021). For reasons detailed throughout this report, some older adults did not use the internet as a substitute to connect with social supports via telecommunication or video-conferencing platforms (Liu and others, 2021).

Certain subgroups of older adults were disproportionately impacted by social isolation, including 2SLGBTQI+-identified older adults. These older adults may have been disconnected from their communities of support or chosen families. In jail settings, the lockdown in cells for 24 hours per day was considered a serious violation of rights and magnified the stress of older inmates. They were not only isolated from other inmates but also from visitors who were suspended from making visits. They were also often denied the possibility of out-of-jail permissions (Aubut and others, 2022). In congregate housing facilities (apartment building for older adults), new forms of resident-to-resident aggression occurred out of the restrictions (Falardeau and others, 2021).

Healthcare service access

Due to a focus on COVID-19 cases and emergency care in the healthcare system throughout the pandemic, access to health services was restricted (Benhow and others, 2021). Further, a reduced availability of informal supports provided by family and friends elevated the strain placed on the formal healthcare system (Beaulieu and others, 2021a). Poor physical health represents a strong MOA risk factor (Burnes and others, 2021b; Burnes and others, 2022a). Older adults experienced restrictions and barriers accessing important health services throughout the pandemic. In some cases, confusion existed as to which services were available. Some older adults were also reluctant to engage with health services, believing that such interactions would increase their risk of contracting COVID-19. These service restrictions and barriers limited older adults from addressing new or worsening health needs and, in turn, elevated their risk of MOA (Benhow and others, 2021). As indicated above, older adults also faced heightened difficulties accessing medications to help manage their health issues.

The Canadian Armed Forces report on long-term care (LTC) settings in Québec and Ontario highlighted several issues during the pandemic. Some facilities were severely understaffed, new employees lacked proper training and orientation, and staff were overworked, exhausted or had poor overall morale (Canadian Armed Forces, 2020a, 2020b). General physicians were also overworked, had a lack of training in psychiatric gerontology, and lacked coordination with other mental health specialists. Psychiatrists were unavailable because of growing demand. In addition, access to psychotherapy was limited because of sanitary restriction measures. With lower access to psychotherapeutic methods, the solution was to compensate with medication therapy. However, medical reassessment and surveillance was limited because of the sanitary restriction measures in effect. Therefore, medication therapy treatments were less safe or personalised (Loussaief, 2022).

The pandemic exacerbated many difficulties already present in LTC settings. The lack of resources and institutional culture of efficiency makes it so employees of LTC facilities can only do the minimum to ensure the safety and survival of residents, to the detriment of their well-being (Lord, Drolet, Vicogliosi, Ruest and Pinard, 2022). To compensate for the staff shortage made worse by the pandemic, provincial governments established an accelerated training program for new workers. However, in some instances, this training omitted adequate training on MOA. This lack of MOA training can lead to MOA, an absence of mistreatment case reporting, and a lack of MOA prevention (Beaulieu, and Cadieux Genesse, 2021).

Mental health challenges

Poor mental health also represents a strong MOA risk factor (Burnes and others, 2022a; Perks, 2021). Poor mental health contributes to lower levels of self-worth or issues of denial, self-blame, and isolation that, in turn, increase susceptibility to MOA and may also serve to reduce a person’s capacity to protect themselves. A higher proportion of older adults reported feelings of sadness, loneliness, and being overwhelmed throughout the pandemic compared to beforehand (Liu and others, 2021; Thivierge and Guay, 2020). Some older adults experienced elevated levels of anxiety around leaving the home to avoid COVID-19 (also contributing to social isolation). A study in France found that social distancing increased the risk of depression and anxiety, and hospitalizations due to suicide attempts (Loussaief, 2022). Mental health challenges among older adults were exacerbated by restricted access to medications and psychotherapy, as indicated above (Liu and others, 2021).

Beyond older adults, mental health risk factors linked to potential perpetrators of MOA were also exacerbated during the pandemic, such as:

• mental health issues
• substance abuse
• stress or burden linked to being a caregiver (Laforest and Tourigny, 2021)

The implemented COVID-19 measures prioritized physical health over mental health. This can lead to the exacerbation of psychological mistreatment of older adults (Beaulieu and Cadieux Genesse, 2021).

Social isolation

Social distancing and stay-at-home mandates throughout the pandemic removed or substantially reduced contacts with:

• informal concerned other social supports (that is, family members, friends, or neighbours in a victim’s social network who provide them with support)
• formal social service, law enforcement, and healthcare providers
• social, recreational, and religious activities in the community
• other social support structures

This social isolation has resulted in fewer opportunities to detect MOA or for older adults to disclose the problem themselves. Agencies involved in preventing and responding to MOA were concerned about the loss of contact with older adults. They were also concerned about the lack of possibilities for them to be heard in public spaces (Bachelet and Broché. 2022). Social isolation is a central, recurrent theme throughout this report that is closely tied to other themes.

Perpetrator control tactics

MOA identification through older adult self-referral or help-seeking was more challenging throughout the pandemic, especially during periods of stay-at-home, self-isolation or quarantine mandates. It was particularly difficult for older adults who lived with their perpetrator. In these shared living scenarios, older adults could not as easily leave the home or find personal space to make phone calls. A perpetrator could use social distancing and stay-at-home mandates as leverage to further limit social interactions with friends and family. This limited opportunities for third-party detection. Detection was also a challenge during remote or virtual-based healthcare and social service sessions. It was not possible to know whether an older adult was alone or in the presence and under the influence of their perpetrator. Power and control dynamics embedded within the victim-perpetrator relationship were heightened for recently immigrated older adults under the influence of a family member (perpetrator) sponsor. The sponsor could use the threat of deportation and financial dependency over the older adult. Recently immigrated older adults also experience language barriers in accessing formal supports outside of the home (Gill, 2022).

The prevention measures linked to COVID-19 increased the use of technology to obtain services and maintain contacts. Yet, older adults who are less skilled in the safe use of technology had more trouble understanding fraud attempts and financial abuse. These tactics were widespread by perpetrators (Meisner, Boscart, Gaudreau and others, 2020).

Surveillance by informal concerned others

Informal concerned other supporters in the older adult’s life (family, friends, neighbours) were less available to visit or make contacts with older adults at risk of or experiencing MOA. This limited the availability of these important third-party informal groups to become suspicious of and detect MOA. Concerned others who would typically check on older adults were reluctant to visit given the risk of exposure to the virus, both for themselves and the older adult. This caused further isolation. Similarly, limits on in-person contact also limited opportunities for informal caregivers (who would normally have eyes on the situation) to detect MOA. Informal places of gathering, such as senior centers and faith-based ceremonies, were closed or restricted throughout the pandemic, resulting in:

• less access to informal concerned others in the community
• increased social isolation
• fewer opportunities for informal surveillance, detection, and reporting

Informal concerned other supports play a critical role in the lives of older adults at risk of or experiencing MOA in both detecting the problem and enabling help-seeking (Burnes and others, 2019).

Homecare availability

As outlined above, the availability of homecare workers throughout the pandemic was limited due to illness, agency policy, and fears of contracting COVID-19 from the perspectives of both workers and families. A reduction of homecare workers decreased the possibility of detecting or witnessing potentially abusive or neglectful behavior.

Remote or virtual services

Social distancing mandates throughout the pandemic elevated the threshold required to justify in-person evaluations from social service, healthcare, and law enforcement professionals. This lowered the likelihood of identifying MOA. In parallel, there was a greater reliance on remote or virtual forms of assessment. However, remote or virtual forms of assessment did not afford practitioners with the same scope of opportunities and information to observe for signs of MOA. Specifically, practitioners could not as easily pick up on or attune to specific psycho-emotional or behavioral responses exhibited by an older adult. They could not observe certain physical indications of MOA over telephone or video-conference platforms. Remote or virtual forms of assessment did not adequately substitute for in-person assessment interactions as they related to detecting MOA.

Availability of supportive response services

As an overarching theme, program interventions designed to respond to and support MOA cases are substantially lacking in general. The pandemic circumstances exacerbated this existing service systems gap. Access to services was limited by:

• social distancing measures
• restrictions to in-person services
• personnel shortages
• shutdowns, in some cases

The pandemic created a particularly vulnerable set of circumstances in which many older adult victims of MOA experienced heightened levels of social isolation without adequate access to responsive support services.

Safety planning

Safety planning is a critical form of crisis intervention to escape or receive help in the face of mistreatment. However, escaping a mistreatment situation was difficult throughout the pandemic for older adults who were cautioned not to leave their home. Finding escape was challenging with restricted access to informal and formal supports due to social distancing measures. Safety planning was particularly difficult for older adults who lived with and were isolated in their home with a perpetrator who had a heightened level of control over their whereabouts. In these scenarios, older adults could not as easily leave the home as a part of their safety plan. They could not contact others outside of the home without personal space to make phone calls.

Perpetrator control tactics

The COVID-19 virus and associated social distancing restrictions provided new opportunities for perpetrators to exercise power and control tactics. Perpetrators could provide misinformation to older adults about how the virus spread to promote unnecessary levels of isolation above and beyond those recommended by authorities. Especially in shared living scenarios, perpetrators could impose or convince older adults to endorse unnecessary social restrictions that prevented others from accessing the home. This could include, for example, informal concerned other supporters, cleaning services or homecare.

In turn, older adults could refuse services and deny access to others who would otherwise provide them with support or serve as third-party monitors holding perpetrators accountable. Deprivation of social interaction and physical contact with support structures made it easier for perpetrators to control, manipulate and mistreat older adult victims. Diverse subgroups of older adults experienced control tactics differently. For example, 2SLGBTQI+-identified older adults may have been housed and isolated with a perpetrator that used outing (for example, “I will tell your children if you don’t…”) or created barriers in accessing necessary healthcare (for example, hormone medication) as mechanisms of control.

Remote or virtual forms of service support

Several challenges were identified in using remote or virtual forms of service support to MOA victims throughout the pandemic. It may not be safe for victims to speak over remote telephone or video-conferencing platforms if they reside with their perpetrator. The perpetrator may be in the same home or room during a virtual meeting. This threatens the older adult’s safety and the integrity of the support provided. The perpetrator may even prevent the older adult from having access to this technology. In addition, some older adults had limited ability to communicate through remote technology due to cognitive or physical (for example, hearing, visual) impairments or did not have the digital literacy or access to the technology necessary to navigate these virtual mediums. Important aspects of the work were undermined through remote forms of service delivery, such as limitations building relationships and trust with clients. These are central components to working with MOA victims and doing work to heal trauma. In some cases, the limitations of remote services were perceived to be potentially harmful. The practitioner was unable to pick up on visual clues or the client’s body language as easily.

Responder safety

MOA responders are accustomed to certain worker safety concerns such as:

• unfriendly or hostile perpetrators and witnesses
• aggressive animals
• infectious pests
• dangerous household hazards

However, the pandemic highlighted additional safety concerns to the workforce. Practitioners had concerns about being infected by COVID-19, infecting clients, or infecting other staff members and family members as a result of in-person interactions. With a reduced availability of informal concerned other supporters in the lives of victims, MOA responders had a particularly critical role in meeting the needs of vulnerable older adults. The unpredictable access to and supply of personal protective equipment (PPE), such as high-quality masks, hazmat suits and gloves, compounded COVID-19-related safety concerns and impeded responders from engaging in in-person sessions. In some cases, clients did not have proper PPE themselves. Responders needed to have a sufficient supply for their clients as well. Finally, many MOA responders lacked sufficient training and knowledge around combatting infectious diseases.

Supporting diverse communities

Older adult immigrants or those from linguistic minority communities may find information about COVID-19 and MOA inaccessible due to language barriers. Immigrant and refugee older adults can be reluctant to access formal support services or receive information about COVID-19 from government-sanctioned entities. They may have had negative experiences with law and government in their home country. Culturally sensitive services and first-language supports are important to ensure that services offered are inclusive, received positively, and that clients fully understand the information shared and can communicate their needs. The way older adults experience the convergence of COVID-19 and MOA varies according to their intersection with different socio-cultural identities. This impacts how they are willing to engage with support services. The potential for bias within the system throughout the pandemic in using health status as a mechanism to discriminate against older adults from marginalized communities must also be recognized and guarded against.

Informal supporters and concerned others

Some victims of MOA access support from informal concerned others in their social network (for example, friends, family, neighbours), rather than working with formal services (Burnes and others, 2019). These concerned others were less available throughout the pandemic to make home visits or support older adults. Older adults also experienced restrictions in their ability to reach out to these informal concerned other supporters.

Age-friendly shelters or other alternative living arrangements

There are very few age-friendly shelters geared toward the needs of MOA victims. Out of a total 500 emergency and transitional shelters in Canada, only 13 (2.5%, in 5 provinces) are focused on older adults. Among the 13 shelters for older adults, only 8 shelters offer full or partial accessibility for people living with functional impairments (CNPEA, 2022). Older adults may need to access alternative shelter models due to age-associated vulnerabilities. Alternative living settings often lack the capacity to support age-associated vulnerabilities, including physical, health and cognitive needs. They also often contain infrastructure that favors younger ages (for example, stairs, cots that are difficult to enter/exit) and program policies that are unrealistic for older adults (for example, requiring residents to leave the shelter all day) (MacNeil and Burnes, 2022). Without suitable age-friendly shelter options or open doors within their social network throughout the pandemic (due to social distancing restrictions), it was challenging to leave abusive scenarios at home.

Organizational capacity

Programs serving MOA victims and their families experienced several challenges at an organizational level. These challenges were related to service capacity throughout the pandemic. MOA responders and program staff who became ill or presented with COVID-19-related symptoms were encouraged to stay home or not work to prevent transmitting the infection to others. There was also a loss of employees due to voluntary layoff. These circumstances contributed to instability (for example, staff turnover, inconsistent schedules) or shortages in personnel (Protecteur du citoyen, 2022). In turn, some programs lacked organization personnel capacity to effectively respond to and support older adults experiencing MOA.

Personnel also experienced strain and mental health challenges as they transitioned to virtual modes of delivery (Montesanti and others, 2022). Many practitioners experienced the mental exertion known as “Zoom fatigue.” This caused them to feel more drained after multiple online sessions. For some providers, it took time to adjust to using virtual video-conferencing platforms. Shifting to virtual delivery considerably altered the way they provided services to clients. Many workers also had to navigate the challenges of technology as a part of their daily services. They had little idea as to how to troubleshoot or fix tech-related problems.

From a resource perspective, the shift to remote work was a serious challenge for many organizations responding to MOA. Throughout the pandemic, organizations incurred additional expenses associated with the adoption of online service delivery, such as:

• purchasing online platforms and equipment to support employees to work from home and conduct remote services
• updating existing technological infrastructure to serve online clients at a larger volume
• strengthening secure servers
• training service providers and clients on how to use virtual platforms
• accommodating clients who had difficulty accessing technology (Montesanti and others, 2022)

The shift to remote work required a substantial amount of information technology (IT) support to negotiate the issuance and maintenance of tablets, smart phones, and computers.

For many years, the Association québécoise des retraité(e)s des secteurs public et parapublic has claimed more investment in homecare to better prevent MOA at home (knowing that the majority of older adults live at home). This plea was renewed during the pandemic (AQRP, 2021). LTC settings also experienced capacity issues with an influx of older adults in facilities. This was the result of a lack of homecare services to meet their needs in the community (Meloche, 2022).

Changing COVID-19 guidelines

Although changes in social distancing guidelines throughout the pandemic were an inevitable and reasonable reality in response to a virus with various strains affecting different numbers of people over time, these guideline changes presented a challenge to organizations involved in MOA prevention and intervention. As guidelines changed, many organizational leaders found themselves building and rebuilding protocols to optimally and safely serve older adults. They did so while preventing exposure to workers. When COVID-19-related guidelines or mandates were introduced or modified throughout the pandemic, the implications of how this changing information affected organizational protocols and operations were not always clear. Program response interventions, for example, needed to clearly understand how changes in COVID-19-related restrictions impacted the way services were delivered. Without this clarity, organizations scrambled to figure out how to deliver services and conduct operations most effectively.

Internet access

Access to the internet became a fundamental need throughout the pandemic (CSQ-FSQ, 2020). As described throughout this report, remote communication was necessary for older adults to maintain social contact with informal supports. It was also necessary to engage with formal healthcare and MOA social services. These connections were critical to both the prevention and response and support for MOA. Internet access was also critical to conduct certain instrumental activities of daily living. These activities included banking and shopping for food or other supplies. Despite the importance of accessing reliable internet throughout the pandemic, some older adults faced access barriers. These included the cost of purchasing computer equipment and adequate internet data plans or having adequate digital literacy around navigating technology and the internet. Access barriers were exacerbated for older adults from marginalized communities who experienced disadvantage on the basis of their social-cultural identity, socio-economic status, or geographic location. Certain rural, remote or Indigenous communities lacked the tele-communications infrastructure to access reliable internet.

Systems capacity

“Many preventable deaths occurred in nursing homes under COVID-19. Some deaths were from lack of timely care, water, food or basic hygiene, not from COVID-19 infection. This underscores the frail and highly vulnerable condition of older adults in nursing homes. It epitomizes our failure. Many are not mobile or cannot vocalize their needs. This was more than a communicable disease crisis.”

Leaders adopted a “hospital-centric” model to manage the pandemic (Meisner, Boscart, Gaudreau and others, 2020; Protecteur du citoyen, 2022; CSBE, 2022b). There was an offloading of beds from hospitals to LTC settings. LTC facilities were not all prepared with additional measures or means to adequately face outbreaks that happened after these changes. Thus, many older adults were infected. The management of these outbreaks was affected by many elements. LTC facilities have a dual purpose that is misunderstood by authorities. They are both a place to live and a place to receive complex care. This misunderstanding has maintained LTC facilities low on the priority list for preparation of a crisis since they are not hospitals (Protecteur du citoyen, 2022; CSBE, 2022b).

The absence of an onsite manager in many living environments led to the disorganization of services. It also rendered impossible the implementation of many sanitary guidelines and changing directives. Risk management was carried out by leadership without the necessary expertise to do it well. A lack of consultation and coordination prevented the implementation of directives in a timely manner. Moreover, infection prevention and control practices and knowledge were not implemented in LTC settings. Outdated information technology also meant LTC facilities lacked information that affected the management of the pandemic. The authorities could not count on updated data to support their daily decision making (Protecteur du citoyen, 2022; CSBE, 2022b). All of these factors created a lack of fluidity in the implementation of guidelines and important negative impacts on the organization of services. In some cases, this contributed to cases of resident neglect. With the outbreak of the virus, many older adults died (Protecteur du citoyen, 2022).

The healthcare system was overwhelmed during the pandemic in response to high numbers of COVID-19 cases. However, interaction with the health system represents a key opportunity to identify and detect older adults at risk of or experiencing MOA. With restricted capacity and access to healthcare encounters in the community and hospital settings, these opportunities were missed. Older adult victims were more likely to remain hidden. The constrained hospital capacity during the pandemic meant that at-risk older adults who interacted with hospitals without a threshold medical need for admission were sometimes sent back home to a potentially unsafe environment. This was because the capacity for hospitals to admit and manage these complex social situations was reduced.

Organizational resources and sustainability

Availability of emergency COVID-19 funding was necessary to support the rapid adoption and implementation of virtual services and interventions among community-based organizations involved in family violence prevention (Montesanti and others, 2022). Some organizations had no funding to support the transition to virtual delivery. Before organizations could apply for emergency COVID-19 funding, many organizations had already incurred costs. This was due to the rapid and urgent need to adapt services and programs to virtual or remote-based delivery. Compounding this financial situation, the re-direction of resources and effort toward pivoting online at the onset of the pandemic meant that usual fundraising activities were put on hold. The unanticipated costs related to transitioning online and a reduction of fundraising revenue resulted in an unstable financial position for some organizations that affected the ability to operate at full capacity toward the prevention and response to MOA.

Sharing lessons learned

As the pandemic unfolded over time, service providers had to pivot and adapt their approaches in accordance with restrictions. Service providers involved in MOA prevention and intervention adapted to social distancing restrictions and the needs of older adults in different ways throughout the pandemic. Further coordination was required to capture and share emerging adaptive practices and lessons learned among service providers across Canada (FPT, 2021). Relatedly, mechanisms and pathways to exchange this knowledge among MOA stakeholders were required to strengthen the system of MOA response.

Quantitative survey responses

Table 2 provides a detailed breakdown of survey responses on items related to the topic of primary MOA prevention. Key survey findings related to primary prevention are summarized as follows:

• overall, based on a catch-all question related to primary MOA prevention, over 80% of respondents agreed that it was challenging to prevent at-risk older adults from experiencing MOA during the pandemic (Figure 1)

• A majority of respondents perceived that further MOA awareness-raising efforts were required during the pandemic that targeted both the general public and professionals who work with older adults. A majority of respondents also perceived that awareness-raising initiatives for the general public require a more tailored strategy to account for the needs and experiences of older adults from diverse communities. Respondents also disproportionately believed that an inadequate amount of training was available during the pandemic for professionals who work with older adults on how to recognize MOA
• Over 85% of respondents agreed that both formal service providers (Figure 2) and informal family and friends had difficulty connecting with older adults during the pandemic. A strong majority of respondents agreed that older adults themselves had difficulty engaging with social activities in their communities, accessing supplies within their communities and that older adults with physical, cognitive, or functional limitations had difficulty accessing at-home informal or formal care supports

• A majority of respondents disagreed that virtual or remote forms of interpersonal or digital communication were feasible or suitable ways of connecting with older adults throughout the pandemic. These forms of communication include:
  • video-conferencing
  • telephone
  • email
  • chat
  • instant messaging
• Over 90% of respondents agreed that informal caregivers experienced heightened levels of stress or burnout throughout the pandemic
• A strong majority of respondents agreed that ageism toward older adults was elevated throughout the pandemic and increased vulnerability to MOA

Qualitative survey responses

Stakeholder responses to the open-ended, qualitative survey questions reinforced many of the results found from the closed survey questions. When asked about what they perceived as being the top challenges or gaps related to MOA prevention throughout the pandemic, the most common response was the heightened levels of social isolation and loneliness experienced by vulnerable older adults. Stakeholders expressed that restrictions to in-person home visits by health and social service programs represented a major challenge in their capacity to assess older adults or conduct check-ins. Further, they described that virtual or telephone-based services as a replacement of in-person appointments was inappropriate and carried heightened MOA risks. They indicated that many older adults struggled with basic technology skills or had age-associated impairments (vision, hearing, movement) that precluded their use of such virtual service delivery. Stakeholders described the disproportionate impact of restricted or cancelled service access on low-income older adults who relied on subsidized or volunteer programs to access basic needs such as food, cleaning, transportation, and library internet access. Several stakeholders mentioned that the absence of transportation services denied older adults access to appointments or obtaining basic resources.

Stakeholders indicated that informal caregivers experienced heightened levels of stress or burden throughout the pandemic. This resulted from the closure of respite services and the limited opportunities for older adult care recipients to attend senior day programming or other community activities. Relatedly, many stakeholders described the elevated MOA risks associated with the shortage and limited access to personal homecare services. They believed that older adults experienced worsened physical and mental health conditions as a result of insufficient home care, limited access to healthcare and depleted social stimulation, which elevated MOA risk. Restricted access to community-based social services, homecare, healthcare, and social and spiritual activities affected opportunities for contact with others which, in turn, elevated MOA risk. Stay-at-home mandates forced people to live and stay at home alone together for extended periods of time under stressful conditions. This increased opportunities and risk of MOA.

Respondents were also asked an open-ended question about lessons learned or perceived best practices in approaching MOA prevention throughout the pandemic. Most commonly, stakeholders indicated the need to maintain some degree of in-person services throughout the pandemic dedicated to older adults. Respondents understood that precautions needed to be taken, such as the use of PPE. However, in-person wellness checks were required to put eyes on the situation and understand a person’s needs. Respondents indicated that regular check-ins were helpful. Respondents described the importance of strengthening efforts in the community that take responsibility for older adult welfare. Such efforts include strengthening existing MOA networks in the community and the communication between agencies that serve older adults. Several stakeholders remarked that further MOA awareness and education efforts were required to prevent the problem. One respondent suggested a large-scale, free online module describing MOA to raise awareness.

Given the emphasis on internet-based technology throughout the pandemic, respondents suggested the need for programs that teach older adults about using this type of technology. Other suggestions or lessons learned included:

• keeping libraries open
• making transportation available (particularly in rural areas)
• offering grocery delivery services without an extra cost burden
• respite services for caregivers
• more robust financial monitoring systems to identify abusive, irregular patterns of transaction
• using local community-based newspapers to communicate about MOA with older adults who live in rural areas

One respondent described a program involving additional outreach workers in the community to assist low-income older adults with basic needs (for example, transportation, reminders about appointments, dropping off food). Several stakeholders described how volunteer friendly visiting programs would help maintain connections with older adults who would otherwise be isolated. Another respondent from a retirement home described how they created small bubbles within their larger home community. They also created hallway activities and fitness classes to get people out of their suites and moving around. Finally, respondents recognized the need for further research to understand effective MOA prevention strategies.

MOA identification and detection

Quantitative survey responses

Table 3 provides a breakdown of survey responses on items related to the gaps and challenges in identifying and detecting older adults at risk of or experiencing MOA. A summary of key findings are as follows:

• overall, based on a catch-all question related to MOA identification and detection, nearly 90% of respondents agreed that the process of identifying and detecting older adults at risk of or experiencing MOA was challenging throughout the pandemic (Figure 3)

• Approximately 80% of respondents agreed that social distancing requirements and restrictions to in-person services during the pandemic created challenges in identifying and detecting older adults at risk of or experiencing MOA. Relatedly, a strong majority of respondents agreed that service delivery using remote or virtual forms of live interpersonal communication (Figure 4) or digital forms of written communication made it challenging to identify and detect vulnerable older adults

• Over 90% of respondents agreed that older adults at risk of or experiencing MOA faced difficulties seeking help or reaching out to services during the pandemic (Figure 5). Also, a strong majority agreed that perpetrators of MOA could more easily use control tactics to divert identification and detection attempts

• A strong majority of respondents indicated that their employment sector or organization experienced instability or shortages in the workforce. This made it challenging to identify or detect older adults at risk of or experiencing MOA

Qualitative survey responses

The qualitative, open-ended questions provided further context to the gaps and challenges in identifying and detecting MOA during the pandemic. The most common response among stakeholders was the difficulty identifying at-risk older adults (for example, red flags, signs of MOA) without seeing them during in-person service encounters. During certain periods, there were no options to conduct home visits or easily meet with clients. It was difficult to assess older adults for MOA through virtual or telephone-based media. To exacerbate the situation, many clients did not have internet access, technology, or the skills or functional capacity necessary to attend virtual assessments and appointments, or they had unstable connections (particularly in rural areas). Providers also expressed confidentiality concerns when conducting meetings from their home if other family members were also working from home or kids were at home doing online learning. Pandemic restrictions also created limitations on older adult privacy as it related to having separation from their perpetrator, which created difficulties in identifying MOA. Safe spaces away from a perpetrator (for example, seniors centres, religious venues) were not open or available for older adults to access and reach out for help. Similarly, it was unclear during virtual or telephone-based sessions whether others were listening to the conversation. An inability to access formal or informal external supports outside the home placed older adults in a position of vulnerability in having to depend upon a perpetrator. Similarly, the physical distancing requirements preventing others from entering the home precluded the possibility of them observing signs of and identifying MOA. Overall, MOA became even more hidden and challenging to identify during pandemic conditions.

When asked about lessons learned or best practices related to MOA identification and detection during the pandemic, stakeholders commonly stated that there is no replacement for in-person interactions with older adults. Regular in-person contact is necessary to listen, ask questions, and observe possible injuries or other signs of mistreatment. These details were missed without in-person contact. Meeting older adults in the community is the best option when possible to ensure safety away from the perpetrator. Access to primary care visits was also mentioned as an important opportunity for identification or detection. Several stakeholders remarked how lockdown and isolation periods during the pandemic created substantial harm for older adults as it related to MOA. Respondents described how important it was to strengthen community partnerships that involve information sharing and developing mutual referral processes. Developing partnerships between community homecare services and MOA response programs was seen as critical to the process of identifying cases and meeting their needs. Particularly in rural areas, establishing such partnership networks was challenging if organizations were competing for the same funding dollars. Several stakeholders remarked how banks could play a larger role in detecting financial abuse and called for greater accountability in the financial sector. Some respondents described the need for a more robust system of checks and balances for Powers of Attorney. Several stakeholders reiterated the need for more training and education among frontline workers and the general public to bolster identification and detection efforts. Finally, it was acknowledged that best practices have not yet been established, and there is a need for further research in this area.

MOA response and support interventions

Quantitative survey responses

Table 4 provides a detailed breakdown of sample responses in relation to survey items on the topic of MOA response and support interventions during the pandemic. Key findings from this section of the survey are summarized as follows:

• overall, based on a catch-all question related to MOA response and support intervention, nearly 90% of respondents indicated that the community-based system of response for addressing and supporting cases of MOA was challenged throughout the pandemic (Figure 6)

• Over 80% of respondents agreed that social distancing requirements and restrictions to in-person services made it challenging to respond to and support MOA victims during the pandemic (Figure 7)

• Over 80% of respondents indicated that it was challenging to effectively respond to and support MOA victims through remote or virtual forms of live interpersonal communication (for example, video-conferencing) or digital forms of written communication (for example, email, chat)
• Nearly 90% of respondents agreed that MOA perpetrators could more easily mistreat victims and obstruct attempts by service providers to support victims during the pandemic
• Over 70% of respondents agreed that their sector or organization experienced instability or shortages in personnel throughout the pandemic. This made it challenging to respond to and support MOA victims
• A strong majority of respondents agreed that it was challenging to maintain a collaborative and coordinated effort within community-based MOA networks throughout the pandemic (Figure 8)

• A majority of respondents disagreed that community-based social services, healthcare services, or other relevant services were available or equipped throughout the pandemic to effectively respond to and support MOA victims

Qualitative survey responses

The qualitative open-ended questions provide a more nuanced portrayal of gaps and challenges in responding to MOA throughout the pandemic. Stakeholders overwhelmingly expressed that the availability of frontline MOA response programs is severely lacking in communities across Canada. Although certain sectors or service organizations end up working with cases of MOA, they are generally not equipped with the specialized knowledge and skills necessary to address this complex issue. Further, referral pathways for MOA response programs are uncoordinated in many communities across Canada. Overall, these MOA response service system gaps were exacerbated during the pandemic, leaving older adults with limited appropriate formal supports. Generally, support programs were unavailable, not easily accessible, or understaffed and lacked capacity throughout the pandemic. Many stakeholders expressed that virtual-based programs were not appropriate for older adults who lacked the basic skills to navigate the technology. Several respondents challenged the basic idea of responding to vulnerable older adults (for example, who may be living with physical hearing or vision or digital literacy issues) using virtual or telephone-based media. They emphasized the barriers to access such technology. Some telephone-based MOA helpline services had long wait times during the pandemic that impeded service engagement. Beyond the availability of direct MOA response programs, the surrounding network of auxiliary support organizations that could typically help support the needs of MOA cases, such as homecare, food delivery, health visits, and others, were also difficult to access.

When asked about lessons learned in responding to and supporting MOA cases throughout the pandemic, stakeholders described the importance of building trust and rapport with older adults as critical for them to open up and move forward with support work. Response and support models must allow adequate time to develop these trusting working relationships. One stakeholder from a rural community described a 2-year position strictly focused on developing connections with older adults to gain trust and have open lines of communication. Programs needed to be delivered in a way that engages the older adult and provides the flexibility to adapt to the needs of each case. Throughout the pandemic, in particular, it was important to be able to connect with and reassure MOA victims through regular contact. Stakeholders described that response interventions, in general, need to target the perpetrator as well as the victim to address the reasons they are mistreating the older adult. To fully address MOA, assessment and response plans must consider cases in relation to individual, relationship, and family-level factors. A more robust, community-based MOA response system was needed. Some stakeholders stated a need to develop and train a specialized workforce of frontline MOA responders who carry the requisite knowledge and skills to work with cases. Such training should be available through dedicated certificate programs or as a part of post-secondary educational programs.

Other lessons learned or suggestions included strengthening the broader MOA networks and communication between programs that are involved in the response system. Several stakeholders identified that MOA-specific shelters needed to be expanded to include more beds and longer, more flexible stay periods until adequate alternatives have been identified. This issue was exacerbated during the pandemic when the alternative could have been to socially isolate with the perpetrator. MOA responders required stable access to PPE. In rural, isolated areas another respondent suggested a need for positions that are dedicated to the needs of older adults.

Centralized systemic support

Quantitative survey responses

Table 5 provides a detailed breakdown of survey responses in relation to items on the topic of centralized or systemic MOA support during the pandemic. Key points related to this section of the survey are summarized as follows:

• overall, as a catch-all question, over 80% of respondents agreed that gaps existed at systemic or structural levels around preventing or responding to MOA throughout the pandemic (Figure 9)

• Approximately 70% of respondents disagreed that efforts to prevent, identify or detect, or respond to and support MOA cases throughout the pandemic were well coordinated across service systems, sectors, and disciplines
• A majority of respondents disagreed that older adults from diverse communities and geographic locations were able to access remote forms of communication and service delivery throughout the pandemic (Figure 10)

• A majority of respondents disagreed that enough resources have been available throughout the pandemic to offset gaps in opportunities to pursue fundraising activities
• A majority of respondents disagreed that systems designed to collect MOA-related data at provincial, territorial, and federal levels worked well throughout the pandemic
• A majority of respondents disagreed that sufficient resources were directed toward evaluating evidence-based practices in preventing, identifying and detecting, or supporting and responding to MOA throughout the pandemic. Relatedly, most respondents disagreed that knowledge around lessons learned in preventing, identifying and detecting, or responding to MOA throughout the pandemic was effectively shared across jurisdictions and service systems

Qualitative survey responses

The open-ended question reiterated some of the above themes in relation to centralized support. Stakeholders expressed concerns about the general coordination across systems and disciplines as it relates to MOA prevention and intervention. It was perceived that coordination of services to address the basic needs of older adults in rural areas, in particular, needs to be strengthened. As a labour force issue, respondents suggested that centralized systems have not adequately responded to staffing shortages, for example:

• for homecare
• nursing home PSWs
• community-based MOA responders

A common concern raised from a systems perspective was a lack of access to internet technology (for example, internet access, equipment, in-person technical assistance), particularly among low-income or marginalized communities. This contributed to inequitable access to services or opportunities for social connection online. Stakeholders stated that campaigns to address the issue of ageism needed to integrate an intersectional lens, for example the perspectives and experiences of older adults representing diverse income, gender, and racialized identities. One stakeholder identified how the Personal Directives and Adult Guardianship or Trustee Acts permit those with designated Powers of Attorney and agent status to conduct older adults’ business without considering their best interest. Consequently, finances and assets are dissolved by the time an investigation commences. Some stakeholders suggested that MOA should be organized as a stand-alone issue, rather than being subsumed under the umbrella of family violence, which tends to be dominated by other domains of interpersonal violence.