Elder abuse, neglect and restraint – research before review

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  2. Elder abuse, neglect and restraint – research before review
  3. References

It has been argued for almost 30 years that there is a disproportionate interest and urgency in the field of child protection compared with the mistreatment of vulnerable older people. The abused child may conjure up a more sympathetic image than that of an abused older person or person with disabilities. Hard evidence – obtained through rigorous research – is required in order to sway public opinion in favour of reducing the likelihood of abuse among adults. The few studies that do exist on either side of the Atlantic are becoming dated and appear less than adequate. Meanwhile, professional concern about the abuse of vulnerable older people continues to grow with new national policy and professional procedures introduced in England and Wales in 2001 (Manthorpe 2002 a, b).

A recent seminar (Action on Elder Abuse 2002) held at the Department of Health in London, UK, highlighted several issues. Professor Karl Pillemer from Cornell University, New York, USA addressed the seminar and, pointing to the vintage of most studies, referred to the ‘woozle’ phenomenon in the literature pertaining to the abuse of older people. Winnie the Pooh allegedly discovered the woozle when he found a set of footprints and followed them round a tree several times, enlisting the help of Piglet. Pooh became convinced that he was on the trail of a very large herd of woozles until Christopher Robin explained that he was causing the footprints himself. This applies to the research on abuse of older adults because some early pioneering work, admittedly not very rigorous, is often cited, leading to subsequent citations of these papers and contributing to the impression that there is a significant and burgeoning literature in the field. The reality is somewhat different and Professor Pillemer commented that ‘the literature on elder abuse is full of unsupported statements, repeated again’. This meant that while there were many reviews, there were little data and that conceptual thinking had been proceeding largely uninfluenced by evidence.

Professor Pillemer praised a pioneering study from the early 1990s in the UK (Ogg & Bennett 1992) especially since it had tried to establish the national prevalence of elder abuse in the UK. However, as one of these pioneers – Professor Gerry Bennett – explained, it had since proved impossible to repeat the study despite many efforts to obtain funding from bodies, which, it could be assumed, might have an interest in the subject.

Research in the area of abuse is not easy. Measurement and definition of abuse of older adults is difficult and the problem is becoming compounded by the reluctance of some ethics committees to grant permission to investigate the problem, especially if the research involves interviews with older adults claiming to be abused. The inception of research governance in the UK (Department of Health 2001) may provide further obstacles to such research as groups of researchers who previously did not routinely seek permission from ethical committees will now be obliged to do so. Clearly, nobody would advocate unethical research but there is considerable frustration in the research community at being prevented from gathering data on a crucial subject by the only means that will provide reliable and valid data – that is from the victims of abuse and, in some circumstances, from the perpetrators.

The situation is improving in the USA. Professor Pillemer described a current study into the national prevalence of abuse of older adults across the USA. The process is facilitated by the standard and mandatory system of reporting abuse in the USA; we lack such a system in the UK. Professor Pillemer has also been able to conduct a case control study, which is the only means whereby the antecedents to abuse can be identified: by comparing abused and non-abused older adults and comparing the independent variables. He emphasized the importance of moving from studies of victims to moving out to the general population. In future there should also be more attention to examining interventions and exploring their effectiveness.

Abuse of older adults is a social problem and one with which social workers are familiar. Nurses are increasingly involved in the detection and reporting of abuse and have much to contribute from their experience with what is becoming recognized as potentially a subtle form of abuse – often perpetrated with the purported interests of the older person in mind – restraint. A recent report from the advisory and campaigning UK charity, Counsel and Care (2002) highlights the ways in which restraint may lead to abuse, a process that has also been identified by the Royal College of Nursing (1999). Other nursing authors have considered the issue of restraint, especially the indiscriminate and unnecessary use of bedrails (Watson 2001). Nevertheless, inappropriate, unethical and illegal restraint persists in hospitals, nursing homes and residential homes. Nurses are the professionals most likely to witness such practice and to command the credibility and professional authority to challenge such behaviours when they are not in the best interests of older people or undermine their rights and dignity.

The answer to the phenomenon of restraint is not simple but some of the components of the solution are obvious. Awareness of the abuse of older adults needs to be maintained and rigorous longitudinal research is imperative. In addition to the abuse of vulnerable older people by their carers the abuse of ageing caregivers by older care recipients must not be ignored (Ayres & Woodtli 2001). Organizations such as Action on Elder Abuse can maintain the issue in the public and professional consciousness and can press for further research. There are groups and individuals prepared to engage with this difficult area of research but large overriding questions remain. Will ethical committees and those taking the lead in clinical governance have the courage to permit research that, by its very nature, cannot be conducted without risk? Will funding bodies, the Department of Health in the UK being a potential prime provider of funds for such research, have the foresight to commission research in this area? For certain, the issue will be there to be researched for decades ahead and, surely, nobody can expect the problem to dissipate without reliable prevalence figures on which to base interventions. We also recommend that issues of abuse and protection become more prominent in the mainstream of nurse training, research and practice development. All studies and practice need to consider the potential for mistreatment or neglect to be happening and to bring on board the possibility that elements of care or treatment may be seen as abusive. In moving issues from the shadows, it should be possible to be more open about the subject and its difficult dynamics. While research on elder abuse itself is long overdue; research in other areas, such as adherence to drug regimes, critical care and emergency treatment, needs to encompass the potential of abuse.

Information on Action on Elder Abuse can be obtained from Action on Elder Abuse, Astral House, 1268 London Road, London SW16 4ER, UK, tel. +44 (0)20 8764 7648, website:


  1. Top of page
  2. Elder abuse, neglect and restraint – research before review
  3. References
  • Action on Elder Abuse. (2002) Seminar on Research Issues Related to Older People and Other Vulnerable Adults 21 January. Department of Health, London.
  • Ayres M.M. & Woodtli A. (2001) Concept analysis: abuse of ageing caregivers by elderly care recipients. Journal of Advanced Nursing 35, 326334.
  • Counsel and Care (2002) Residents Taking Risks: Minimising the Sue of Restraint – a Guide for Care Homes. Counsel and Care, London.
  • Department of Health (2001) Framework for Research Governance in Health and Social Care. The Stationery Office, London.
  • Manthorpe J. (2002a) Assessing elder abuse in institutional settings. Nursing Older People 14(1), 2728.
  • Manthorpe J. (2002a) Assessing elder abuse in the community. Nursing Older People 13(10), 2728.
  • Ogg J. & Bennett G. (1992) Elder abuse in Britain. British Medical Journal 305, 998999.
  • Royal College of Nursing. (1999) Restraint Revisited – Rights, Risks and Responsibility. RCN, London.
  • Watson R. (2001) Restraint: its use and misuse in the care of older people. Nursing Older People 13(3), 2125.