Understanding Elder Abuse in Italy

UNDERSTANDING ELDER ABUSE IN ITALY: PERCEPTION AND PREVALENCE, TYPES AND RISK

FACTORS FROM A REVIEW OF THE LITERATURE

Shortened title

ELDER ABUSE IN ITALY: A REVIEW OF THE LITERATURE

Maria Gabriella Melchiorre

Scientific Technological Area, Centre for Socio-Economic Research on Ageing,

Italian National Institute of Health and Science on Aging (I.N.R.C.A), Ancona, Italy

Bridget Penhale

School of Nursing Sciences, Faculty of Medicine and Health Sciences,

University of East Anglia (UEA), Norwich, UK

Giovanni Lamura

Scientific Technological Area, Centre for Socio-Economic Research on Ageing,

Italian National Institute of Health and Science on Aging (I.N.R.C.A), Ancona, Italy

Address correspondence to: Maria Gabriella Melchiorre, Italian National Institute of Health and Science on Aging

(INRCA), (http://www.inrca.it), Scientific Techonological Area, Centre for Socio-Economic Research on Ageing, Via

S. Margherita 5, 60124 Ancona, Italy; Tel.: +39 071 8004887; Fax.: (0039) 071-35941; E-mail address: [email protected]

1 ABSTRACT

The paper aims to perform a review of studies on elder abuse in Italy. Hand searching of grey literature and reviews of the published papers, concerning local, national and cross-national studies, both in Italian and English languages, was undertaken. Inferences mainly about perception and prevalence, types and risk factors, but also concerning victims and perpetrators when data were available, have been derived through the quantitative and qualitative information collected.

On the whole, elder abuse in Italy, with a prevalence rate around 10-14%, is characterized by more female victims, especially in the oldest age groups. The risk of psychological abuse is highest, but the level of financial mistreatment is also high. In domestic settings, difficulties of over-burdened family caregivers have been associated with the existence of possible episodes of abuse, which often remain hidden; in institutional settings, neglect of dependent persons, expired medications and lack of hygienic conditions represent the most common forms of reported abuse, with the help of

Police Inspections. In both settings the use of physical restraints emerges as an area of concern. Although caution is needed in relation to generalization, the available data suggest the existence of a widespread phenomenon of elder abuse in Italy, but more in-depth research is needed to provide further evidence and to raise the currently relatively low general and professional awareness of elder abuse. Moreover, a dedicated legal framework and protocol for tackling and preventing the phenomenon, and ad hoc support services for the victims, need to be urgently addressed.

2 BACKGROUND

The European context

Abuse and mistreatment of older people, by family or professional carers, is a growing health issue in developed countries, although it often remains ‘underrecognized, underreported, under-prosecuted’ (Bomba, 2006:104) The phenomenon covers social and legal aspects, and includes different categories - physical, sexual, psychological, financial abuse and neglect (McCreadie et al., 2006) - with evident health effects, such as increased risk of morbidity and mortality rates in older adults who experienced mistreatment (Dong, 2005). The first empirical evidence concerning the extent and characteristics of elder abuse (Ogg & Bennett 1992; Comijs et al., 1998), showed a rate of abuse of 4-6% among older persons. A further systematic review of studies regarding the prevalence of elder abuse and neglect in various countries (Cooper, Selwood, & Livingston, 2008) has highlighted a rate that ranged between 3.2-27.5% in general population studies. An extensive and more recent review on European prevalence rates of elder abuse (De

Donder et al., 2011:137) highlighted that psychological abuse (explored by 67% of studies), was the most common form reported by older people, followed very closely by neglect (62% of studies included questions on it). The main risk factors for elders are cognitive and physical disabilities (Ansello & O’Neill, 2010), female gender (Luoma et al.,

2011), isolation and limited social interactions and stress of caregivers (WHO, 2006; Dong, Beck, & Simon, 2010). In a further study in Ireland (Naughton et al., 2012), lower income and poor social support were found to be associated with a higher risk of abuse, with social support and mental health being independent predictors. On the whole mental incapacity of cared for might be a risk factor for financial elder abuse (Davies et al., 2013). In any case, most research on elder abuse has included limited attention to episodes in institutional settings, and prevalence studies have focused mainly on domestic violence. With regard to evidence for institutional abuse, a review of the research (McDonald et al.,

2012) showed that recent studies were carried out only in Germany and Sweden (besides the United States of America -

USA). A further review on overall restraint in care homes for older people (Qureshi, 2009), found a great degree of variation in rates of use of physical restraints, from less than 5% of residents in Denmark and Scotland, to 40% in

Spain. Inadequate staffing levels and lack of supervision may lead to associated outcomes of neglect and mistreatment as well as contributing causative factors (Lindbloom et al., 2007). In institutional settings mistreatment also results from a lack of training (skills, knowledge, competencies) of care staff (DeHart, Webb, & Cornman, 2009).

The systematic review from Cooper and colleagues (2008) also showed that on the whole the phenomenon of elder abuse was reported by 6% of older people, 5% of family caregivers (with regard to physical abuse towards older relatives with Dementia), and 16% of care home personnel (in the form of psychological abuse towards older people).

With regard to the potential abusers, comparative data (Special Eurobarometer, 2007) show that 47% of European

3 Union (EU) citizens perceive neglect and abuse of dependent older people to be a serious problem, underlining that the perceived ‘offenders’ of such situations are above all staff working in care homes (32%) or in the person’s home (30%).

The majority of Europeans also perceive that older people are a fragile group at risk of psychological (64%) and physical (52%) abuse, with women perceiving both as widespread slightly more often (67% and 54% respectively) than men (62% and 50% respectively).

In recent years, important progress has been made in increasing awareness of elder abuse around the world and within diverse cultures, but mainly in the United Kingdom (UK) and other Northern European countries, besides the United

States of America (USA), which was indeed the most frequently listed of the identified countries of origin (Erlingsson,

2007; Cooper, Selwood, & Livingston, 2008).

The Italian context

With regard to Italy, very limited information has been made available so far in the international literature. An interesting overview on elder abuse in Europe, showed that in Italy in 2006 there were “no national projects concerned with elder abuse yet and virtually no research on the topic until now”. There were however “some local regionally based initiatives, which have been developing since the late 1990s” including helpline and educational programmes for professionals (Penhale, 2006:113-114), e.g. the telephone helpline AUSER (a national NGO linked to older people).

Furthermore, the review already cited above from Cooper and Colleagues (2008: 153) mentioned only one study on

Italy by Ockleford and colleagues (2003), and another review on public perceptions of elder abuse (Lafferty, 2009) mentioned only one study by Daskalopoulos and Borrelli (2006). With regard to perceived data we found also some comparative data from the Special Eurobarometer (2007)1. A more recent and extensive literature search, which was conducted in most European countries, showed that “no prevalence study on elder abuse was found” in many countries, including Italy (De Donder et al., 2011:139). With regard to elder abuse in institutional settings in Italy, results from the abovementioned few studies, which offer cross-national comparisons (McDonald et al., 2012; Qureshi, 2009), revealed that Italy was never mentioned among investigated countries. Nonetheless, we found some general indication of episodes of abuse against Italian older residents in care institutions, perpetrated by staff at all levels, (Santanera &

Breda, 1987; Ripamonti, 1995) in a 'White Book' which was published at the end of the 1980's. Furthermore, Cester

(1995) provided evidence that these cases of mistreatment in institutions were particularly evident in some Northern

Regions (e.g. Liguria and Emilia-Romagna), in addition to a widespread use of psycho-pharmaceuticals. Nevertheless, besides the general and limited information on elder abuse in Italy, both in domestic and institutional settings, recent data on voluntary homicide in Italy (EURES-ANSA, 2009) highlighted the increase of cases within the family, as

1 A more in-depth analyses of Ockleford et al., 2003 is available in Table 4; a more in-depth analyses both of Daskalopoulos & Borrelli 2006, and of Special Eurobarometer 2007, are available in Table 1. 4 markers of prevalence of physical abuse (+3% than 2008). From this information, the largest proportion of victims were women (75% vs. 25% of men) and aged 25-54 years (50.2%), but there was a rate of 22.8% of over 64 (increased from

21.7% in 2007). Among the reasons for the homicide there were also the contexts relating to heavy/strong discomfort with and serious disease of the victims (9.6% of cases). Moreover, empirical evidence from Italian newspapers has highlighted that although the media reported mainly cases of frauds and thefts, there are also reports of poor care quality and neglect due to care staff (Moretti & Uda 2009). However, reports relating to domestic violence were still greatly hidden, apart from bloody episodes or high-profile cases related for instance to an older father or mother killed by their children, mainly due to mental or physical impairment of the victim or of the perpetrator (Merzagora Betsos, 2007). The

Italian media also reported cases of older people threatened by their children to obtain money or harassed by a private caregiver (badante in Italy)2 (Melchiorre, Chiatti, & Lamura, 2012), and cases of older people neglected in hospitals both by staff personnel (Forgnone, 2012) and by their relatives during the Christmas holidays (Caverzan, 2010).

The Italian “picture” on elder abuse, painted above, thus suggested an existing phenomenon, which was largely revealed by the media but rather “neglected” as an issue by current studies and research. Therefore, in an attempt to analyze the extent and characteristics of elder abuse in this country, the starting point for this work was that so far we have very limited information. A further consideration regarded the awareness of different levels of development of prevalence research on elder abuse and neglect throughout the European countries (De Donder et al., 2011), with Italy having just begun to investigate this aspect at national level. Moreover, there was evidence that estimated prevalence and other characteristics of elder abuse may vary between countries and also between studies within the same country, thus probably reflecting real cross-national and cross-cultural variations in rates of elder abuse, as well as differences in definitions and categories of elder abuse, and in instruments used to measure the phenomenon (Cooper, Selwood, &

Livingston, 2008; De Donder et al., 2011; Daly, Merchant, & Jogerst, 2011).

All these considerations thus highlighted that a review on prevalence, types and risk factors of elder abuse in Italy was needed, and the specificity of the mandate, in addition to the issues that this might raise for elder abuse in Italy, encouraged us in this direction, in order to gain and “denounce” a more complete picture of what might be happening in

Italy in this field.

METHOD

2 In Italy the term badante indicates a privately paid personal assistant, usually foreign-born, who is hired by families using cash-for- care payments to provide an around the clock assistance to the dependent person.

5 The specific objectives of this review were:

1. to analyze and summarize/organize findings from the current literature and various documents on the

phenomenon in Italy;

2. to describe perception and prevalence of abuse, types and possible risk factors for elder mistreatment, in

addition to characteristics of victims and perpetrators, and prevalence period, when data were available;

3. to improve recognition of elder abuse and neglect from the information collected through different sources, as

these deliver snapshots of aspects which are related, in various ways, to the topic;

4. to help to raise awareness on the phenomenon in the general population; finally to identify gaps in

information/limitations of these studies to be overcome in further studies.

Review framework

Following on from these aims, and due to the scarcity/lack of available studies and information on elder abuse in Italy, our literature review has been carried out without using a rigorous systematic approach to identify and critically select/evaluate findings from the studies included, nor answering specific, and a priori stated research questions. Our review, by using in any case a reasonable methodological approach, and by summing up and disseminating various findings and identifying gaps in the existing literature (Arksey & O’Malley, 2005), can furthermore potentially

“strengthen” and integrate the high-recall search and the more critical appraisal coming from a systematic selection of studies (Collins & Fauser, 2005). Our literature review used also a descriptive/narrative method and a topical/scoping approach, which seemed the most appropriate due to the exploratory nature of the study, which is aiming at “mapping” recurring issues within the existing research and literature (Arksey & O’Malley, 2005; Collins & Fauser, 2005), thus allowing for a comprehensive coverage of the particular/crucial topic of elder abuse.

Literature collection

Due to these reasons, we did not choose strict and precise inclusion/exclusion criteria as prescribed by the method of the systematic review. Conversely, we undertook a wide search of studies, research, Police inspections and policy documentation, in order to cover a wide range of issues within the topic, and to gain a broad perspective/overview on it.

Moreover, we did not follow specific rules about the search for evidence, and did not consider the relevance and validity of the included studies. Thus, we conducted a comprehensive hand search and collection of grey literature

(research articles including those not peer reviewed, books, research reports, conference proceedings, unpublished material), both in Italian and English languages, suggested from our own experience and knowledge of the topic, and

6 from key scientists/experts in the area we consulted. This was in addition to further studies which were identified from the bibliographies of relevant primary literature and review articles on elder abuse. We selected “pivotal” papers known to the authors and all material performing data/information covering at least one of the following aspects/findings: perception of the phenomenon, measures of prevalence, types of elder mistreatment, possible risk factors. Our review included bibliographic material regarding elder abuse in Italy, with reference both to cross-country studies (within the

European context) and local/national sources, and when related to the issue in various settings, by distinguishing between domestic and institutional situations. We included both genders, any type of study design and any definition of elderly group. For the purposes of this review, from the selected papers we extracted the abovementioned key information, in addition to: first author/s and published year (source); name of the Study (if any); year of the study;

Italian Regions/cities covered; sampling strategies/size and method/tool/measures used for data collection (in order to know how the studies conceptualise and measure elder abuse); specific focus (if any) or different/more general focus.

We did not include specific studies focused on measures and actions (best practices or guidelines) to prevent or to combat all types of violence, but not reporting any finding on the specific phenomenon (e.g. prevalence rate, types, and so forth), and thus not quantifying the prevalence, characteristics and dynamics of elder mistreatment. All these selected/collected information were synthesized in data summary sheets which were used as framework for each study included in the review, and they produced the evidence/references reported in Tables one-five, thus providing an overview of information about the extent of elder abuse as found and reviewed for Italy. Further information on the prevalence periods and on characteristics of victims and perpetrators were given in the “Findings” column, when available and when found in the articles/books analysed. Out of the 25 publications/studies included in the review, we found: 11 in English language, 14 in Italian language; 5 on local studies, 12 on national and 8 on cross-national ones; 13 in domestic settings, 11 in institutional settings (7 from Italian Police Inspections), 1 for both settings (i.e.

Eurobarometer Survey 2007 on perceived data).

The review has been carried out during an extensive period of time between October 2009 and June 20133.

RESULTS

Perceptions of elder abuse in Italy

Understanding how people in Italy define and perceive abuse is crucial. A national exploratory-qualitative study carried out in the first half 2000s (over several years) (Daskalopoulos & Borrelli, 2006) investigated cross-cultural definitions

3 This review contains updated and more extensive data and analyses from the introduction of authors’ previous work in Melchiorre et al., 2012. 7 of family violence and abuse by adult children towards their ageing parents, by analyzing given examples of severe/extreme, moderate, and mild abuse (Table 1).

Psychological abuse (e.g. “blackmailing him/her”) and neglect (e.g. “leaving the parent alone during vacation”) were the most common response categories given as examples of moderate and mild abuse, whereas most extreme examples made reference to physical abuse (e.g. “hitting him/her”) and neglect. On the whole, examples of neglect were mentioned with a same frequency at all levels of severity, but physical violence was reported as a form of extreme aggression. With regard to gender differences, more females than males made references to physical neglect. With regard to age differences, older participants were more likely to mention physical neglect as a moderate form of elder abuse, rather than moderate or severe.

In addition, the Special Eurobarometer Survey (2007) carried out in 2007 explored (besides other issues such as lifestyle and long-term care of the older adults) the perception of elder abuse among Europeans. The Italian respondents underlined first of all the abuse of property and psychological abuse, and levels of physical abuse were also perceived to be rather high. The perceived offenders/perpetrators reported were above all care workers/home help/nurses working in the person's own home, staff in a care home and children of an older person. Moreover, Italian citizens identified much more frequently severe punishment for perpetrators and strict controls by a government agency as crucial actions to prevent elder abuse: Poor living conditions, lack of attention to physical needs of the elders and deteriorating health due to inadequate care were also considered to be crucial risk factors.

Extent and characteristics of elder abuse in domestic settings

Local studies

Romito and Gerin (2002) carried out an estimation of the prevalence of domestic violence towards women attending social and health services in Trieste (Northern Italy) (Table 2). Among the women aged 65-92, about 5% experienced physical/sexual violence in the last twelve months, and in two-thirds of cases this was perpetrated by a male partner (or former partner). Marital status and precarious economic situations of the older women seemed to be major risk factors.

8 A second study (Romito et al., 2004) was conducted in Belluno (Northern Italy) with regard to women who were the patients of six General Practitioners. The findings confirmed episodes of violence towards 6% of older women from their partners, and mainly of psychological nature.

The project called DIADE (Ligabue, 2010) was carried out in the Province of Reggio Emilia (Northern Italy), and investigated the complex reality of violence perpetrated or suffered within a caregiving relationship at home, involving the personal assistant (usually named badante), the family carers and the cared-for older person. The abusive acts were perpetrated in 35% of cases by personal assistants of the cared-for older people, mainly physical and psychological abuse. Also episodes of abuse of personal assistants by family carers (29%) and older people (23%) were detected

(mainly sexual molesting behaviours and verbal aggression). Several risk factors have been identified by this study: stress related to heavy working conditions for the personal assistants; presence of cognitive pathologies and social isolation for the cared-for older people. For both parties, the enforced cohabitation was found to be a serious risk factor.

A smaller local study (Caritas Ambrosiana, 2011) was carried out in five cities of Lombardia Region, and found evidence for episodes of psychological elder abuse within the caregiving relationship in 86% of cases, and daughters were found as main perpetrators. Behavioural disorders and dementia were major risk factors for older people, whereas stress related to caregiving, dependency between carer and cared for, and duration of care were found as major risk factors for the carergiver.

National studies

Among national studies (Table 3), two did not focus explicitly on elder abuse, but in any case these have highlighted data on the topic. The Silvernet study (Ogioni et al., 2007) allowed for an estimate of the presence of ‘signs of potential abuse’ (i.e. the older person is fearful of a family member or caregiver, poor hygiene, unexplained injuries, neglect or mistreatment, physical restraint use), since it used the Minimum Data Set for Home Care (MDS-HC) to assess the older person’s status.

The findings showed that almost 10% of respondents reported abuse, mainly in form of physical restraints and poor hygiene. Despite the absence of specific information on perpetrators (generically primary caregivers), this epidemiological study identified important risk factors for abuse and neglect (oldest age, widowhood, physical disability, dementia, urinary and bowel incontinence). For the caregiver a fragile psychological status and feeling lonely represented major problems in terms of risk factors for abuse.

9 Similarly, the national survey on women’s safety, which was carried out by the Italian National Institute of Statistics

(ISTAT, 2007), has provided specific information only on the total prevalence of violence against women aged 16-70 years. Few detailed data by age group were thus available, and the related findings showed low rates of reported physical and sexual abuse (during the last 12 months) affecting women aged 55-70 years (1.4% for both types), with the main perpetrators being current spouse/partner, rather than a former one. Thus, for older women, to have a spouse- partner seemed to be a potential risk factor. Although elder abuse represented only a ‘marginal’ topic for this source, its representativeness and large sample size (over 25 000 respondents) account for the reliability of its findings.

A further more comprehensive and national survey of violence against older people (Sgritta & Deriu, 2009) provided finally specific data on the topic, with 9% of respondents reporting psychological abuse, and about 3% fraud and theft, whereas only about 1% experienced either physical abuse or neglect. Regarding the perpetrators (no data but only general qualitative information), these were mainly children and young people in case of psychological abuse, strangers in case of physical abuse, and sons/daughters and partners in case of neglect. Relevant risk factors were largely associated with health problems, but also with marital status (widowhood), retirement, dependency and a previous history of abuse. It is notable that these risk factors were reported by the older people mainly as “personal situations” which made them vulnerable and unsafe.

Cross-national studies based on EU-funded projects

A cross-national study (Ireland, Italy and UK) on recognition, prevention and treatment of abuse of older women (Table

4) was undertaken within the Daphne Programme (Ockleford et al., 2003). In the Italian sample 14% of older women reported experience of some form of mistreatment (actual abuse); 10% reported financial abuse, 4% physical and again

4% psychological abuse. Also the professionals working with older women (e.g. care workers, social workers, mental health professionals) reported experiences of abuse of their clients (88% of these related to psychological abuse). The source of mistreatment was reported with regard to the overall sample of the three investigated countries, and in 66% of the physical abuse cases a spouse or other family member were detected as perpetrators. Women living alone in particular appeared to face a major risk of abuse.

Within the AgeD in HOme Care (AdHOC) study, funded by the EC Vth Framework Programme (Cooper et al., 2006),

‘markers of suspected abuse’ (by MDS-HC instrument, the same used in the abovementioned Silvernet Study) were detected with regard to older people receiving health or social care services in eleven representative European countries.

10 Some 12% of the Italian sample (the highest rate among participating countries) were positive for at least one indicator of abuse. The use of physical restraints was also more frequent in Italy than elsewhere in Europe, accounting for 88% of the reported abuse cases. This might relate however to higher levels of dependency in the Italian participants, who showed the highest rate of positivity to the dementia screening measure that was used. Elder abuse was associated with potential risk factors such as depression and dementia.

A further cross-national research project was ABUEL – ELder ABUse: A multinational prevalence survey4 (Soares et al., 2010; Melchiorre et al., 2012; Lindert et al., 2012), which had the objectives of providing data on the extent and nature of elder abuse. This study was financed in the research programme area of the European Agency for Public

Health (EAHC) and seven urban European centres took part. In Italy an overall prevalence rate for abuse of 13% was found. The prevalence of victims was higher among males, with 19% of cases, compared with 9% of the females. This specificity from the ABUEL survey was also found in Sweden, whereas in the remaining countries mostly older women were the main victims of abuse, this has also been found in results from other studies on the phenomenon. The principal forms of abuse found in Italy were mainly psychological and financial (respectively, about 10% and 3%), whereas very few cases of physical and sexual abuse were detected. Among the perpetrators found (Melchiorre et al., 2012), these were mainly relatives (spouses and/or partners) and friends for psychological abuse, whereas in the case of financial abuse there was a significant quota of “other” people (strangers, colleagues, service workers). Aspects such as low socio-economic conditions (i.e. low levels of education, especially divorced and separated individuals, artisans and labourers/workers, with disability pension, care allowances and various subsidies as the main source of income), poor health (i.e. suffering from anxiety, depression and physical complaints), in addition to social isolation and lack of social support, were detected as crucial risk factors for abuse.

Extent and characteristics of elder abuse in institutional settings

Local studies

The crucial issue of physical restraint and elders in institutional settings was explored by only one local study (Table 5), which examined the knowledge, feelings, attitudes and use of restraints by nursing staff with older people admitted to hospitals and residential care facilities in the Udine district (Northern Italy) (Papparotto, Zuliani, & Ferrara, 2009).

4 In the review on elder abuse in Europe by De Donder et al. (2011) the ABUEL project is cited. However “at the time when the literature search was undertaken [summer 2009], the project had not published data or information on the research results” (p. 141). Indeed the first findings from the survey, including analyses by Countries, were published in 2010.

The findings showed that 33% of the nurses who were interviewed had a correct knowledge of restraints, bed rails being the most frequently used measure (87%). Among the most frequently mentioned alternatives, the continuous supervision of the patient and the use of sedative medications were mainly reported. The patients reported as having the highest probability of being affected by this type of constraint were mainly older people at risk of falls, those with some form of violent behaviour and those suffering from confusion and behavioural disturbances. The lack of education/training about restraints for nurses represented a major further problem/risk.

National studies

A principal source of information in this sector, and at a national level, is represented by reports following the periodic

National Police (unannounced) Inspections carried out in residential care settings by Special Units of the Italian Police

(NAS) (Prospettive Assistenziali, 2001; 2002; 2004; 2005; 2009). The wave of inspections carried out in 2008

(Prospettive Assistenziali, 2009) have revealed in particular a large number of situations of mistreatment and neglect

(such as lack of hygienic conditions, expired medications and rotten food), in addition to facilities characterised by not having adequate organisational/care procedures. Potential risk factors have been identified in the lack of adequate staff care, especially if underpaid, in situations of staff burn-out and a lack of training opportunities (Prospettive

Assistenziali, 2005).

The last available National Police Inspections of residential facilities for older people (with extension of the inspection also to hospitals) (Perrone, 2012; Senato della Repubblica, 2012), revealed “crimes”, as irregular-illegal practices of health professions, neglect of dependant persons, episodes of expired medications and mistreatment. Lack of regular- adequate organisational/care procedures and of trained care staff (who were often identified as perpetrators) were highlighted as key risk factors.

A further national source of data on institutional abuse of older people was represented by the First National AUSER

Research on Nursing Homes in Italy (AUSER Nazionale, 2011). This mapping allowed for the collection of differentiated information on the investigated structures (e.g. territorial diffusion, frequency of presence of health care staff, social workers and psychologists). Further, the presence of cases of abuse was investigated by analyzing various articles on the phenomenon published in 90 national and local Italian newspapers. Overall, mainly the lack of permission/adequate structures, low hygienic conditions, unqualified staff, malnutrition/abuse and expired medications were recorded as infringements

12 Cross-national studies

The study on the use of restraints in nursing homes from Ljunggren and colleagues (1997) was based on data collected with the Minimum Data Set/Resident Assessment Instrument (MDS/RAI) from eight countries participating in the interRAI collaboration5. The related findings have clearly shown the high rates of physical restraint (ab)use reached in

Italy in the first half of 1990s, when about 17% of residents were found to be restrained on a daily basis by any type of measure (13.5% in particular by chairs which prevented people from getting up). High physical dependency and high rates of cognitive impairment of older people, in addition to low staffing levels and training, were found to be potential risk factors for the application of restraints.

With regard to facilities for older adults people, a not recent but still relevant multicenter study (three countries) was carried out within the national clinical-research Project “Alzheimer Plan” (Bellelli et al., 1998), and in Italy 8 special care units for patients with dementia in nursing homes (SCUs) in the Lombardia Region were involved. This study showed a different starting point, because it didn’t investigate cases of abuse in institution, but on the opposite it evaluated the effectiveness of the SCUs in improving the cognitive, functional, and somatic health status of older patients, and in reducing the use of psychotropic drugs and of physical restraints. Specific care programmes (including occupational therapy and recreational activities) were implemented in each SCU, and the assessment after 6 months follow-up from admission revealed the improvement in decrease of behavioural disturbances occurring together with a reduction in physical restraint and psychoactive drug use.

DISCUSSION

Main findings

Drawing on the reported findings, and despite the limitations-differences of information-data we found (which are reported below), this article has provided an overview of the most relevant aspects of elder abuse in Italy, and cues for reflection for anyone – professionals or not – concerned to address the issue of how to tackle and prevent mistreatment in this country.

5 “ InterRAI is an international collaborative to improve the quality of life of vulnerable persons through a seamless comprehensive assessment system”. http://www.interrai.org/

13 A preliminary observation concerns the understanding of what is meant by/perceived to be ‘elder abuse’ in Italy. This appeared to be characterised much more in forms of psychological mistreatment neglect, rather than other forms of abuse as physical assault, which were considered as less frequent but more aggressive (Daskalopoulos & Borrelli, 2006;

Specaial Eurobarometer, 2007). The high number of neglect examples reported confirmed the primary key role played by the family as carers of older relatives in Italy (Melchiorre et al., 2010). Moreover, the pattern highlighted by

Daskalopoulos and Borrelli (2006) also indicated that the older the participants were, the less concerned they were with physical and psychological neglect, or also the less precise they were in specifying the types of neglect that they considered abusive. Older age thus seems to be linked to a lower awareness of the phenomenon of elder abuse, and the fact to be/to feel older could also act as a sort of unconscious and self-justification for eventual episodes of experienced mistreatment.

Moving from perceived data to consider findings from various studies, we found mainly cases of psychological abuse, but also neglect and less physical violence within the domestic setting, with an overall low prevalence of elder abuse ranging 10-14%, which is the lowest (13%) among seven European countries according with the results from the

ABUEL study (Lindert et al., 2012). It is noteworthy that in Italy a large proportion of the abusive episodes often remained unrecognised (especially in case of verbal abuse) and thus not admitted and un-reported when happening within domestic-private settings, and thus in this context the phenomenon often appeared virtually hidden and invisible.

This seemed to be at least partly associated with the existence of an over-burdened caregiving situation. Due to the

Italian traditional family, as already highlighted, but also due to high costs of nursing home care and a lack of supportive social-health policies (Melchiorre, Chiatti, & Lamura, 2012), many older people still live together with children in the same house, who care for them in stressful conditions, where episodes of abuse can easily occur. In particular, we found reports of potential psychological elder abuse by relatives or primary family carers (as sons/daughters and partners) mainly in situations of behavioural disorders and dementia of older people and in the case of high levels of mutual dependency between carer and cared for (Caritas Ambrosiana, 2011), but also in cases of

‘forced’ cohabitation, which increasingly involved the emerging figure of the privately paid personal assistant (Ligabue,

2010). Further, in domestic settings, physical disability and urinary and bowel incontinence of the elders were also risk factors for elder abuse (Ogioni et al., 2007), in addition to low socio-economic conditions, and individuals suffering from anxiety, depression and physical complaints, social isolation and lack of social support (Melchiorre et al., 2012).

We found also “irregular situations” within institutional settings, with lack of regular-adequate organisational/care procedures and of trained-qualified care staff, including neglect of dependent/incapable persons, episodes of expired medications, poor hygienic conditions and malnutrition. Elder abuse occurring within this setting also remains hidden, and it is often detected by Italian Police (NAS) in their inspections and usually reported by the media (AUSER

Nazionale, 2011). In this setting key dimensions appear to be a sufficient number of care workers (possibly not

14 underpaid and without bad working conditions characterized by burnout), a multidisciplinary mixture of professions involved, and a rigorous selection and training of care staff (Prospettive Assistenziali, 2009).

In both settings, domestic and institutional, the widespread use of physical restraints (mainly for older people with high levels of physical dependency and cognitive impairment) has emerged as potentially problematic. This use is not always culturally and necessarily considered a form of abuse, i.e. if the person is a danger to himself or others. Elder abuse by use of physical restraints may indeed be perceived as more acceptable-justifiable in situations where the older person has a mental health problem and thus may be difficult to care for. Furthermore, this context itself increases the vulnerability of older people to mistreatment, and it probably reflects the absence of an effective national legislation and policy guidance concerning this topic (Ljunggren, Phillips, & Sgadari, 1997; Melchiorre, Chiatti, & Lamura, 2012). In this respect, the study by Bellelli et al. (1998), clearly represented a sort of indirect confirmation of the negative consequences of restraint use in the elders, and conversely highlighted the positive impact of adequate structures/processes and trained care or nursing staff in reducing the use of physical and pharmacological restraints, thus assuring a better quality of life for older people with Dementia who were at risk of abuse.

Moreover, cases of financial abuse, especially in the form of fraud and thefts, were found. These cases appear to be recognised and denounced by victims as criminal offences more frequently in Italy, and are frequently reported by newspapers. In these situations the perpetrators were often not familiar or were unknown “other persons”, and thus it seemed easier for the abused older person, to report the related episodes (Melchiorre et al., 2012). Nevertheless, it is arguable that when the financial abuse occurs within the household (Soares et al., 2010), it would be hidden (only 3% in the ABUEL study) due to emotional reasons (in case the abuser was, for instance, a son/daughter), but also due to the fact that the older people could consider it natural to financially support their children, and thus they tend to perceive such a context as something rather different from abuse.

A final consideration was that, in general, the little available data still allowed confirmation that elder abuse had a gendered imbalance, with older Italian women being much more at risk of physical-sexual-psychological abuse

(perpetrated by a male, also former partner) than older men, and especially belonging to the oldest age groups, living alone but also with a partner/spouse, and with poorer living conditions, poorer physical or psychological health. This was the case with the exception of the ABUEL Study (Soares et al., 2010), which on the opposite showed a higher prevalence of male victims, who reported mainly psychological and financial episodes. Moreover, the female victims tend often to be silent on the abusive acts they had experienced and these were rarely reported to the Police (ISTAT,

2007; Ockleford et al., 2003; Melchiorre et al., 2012). It is also necessary to consider that differences in victimization risk among different age groups, found in evidence from the ISTAT survey 2007, should be interpreted with great caution because this could hide different tendencies of women to talk about the suffered violence, with older women in

15 particular probably being more reluctant and ashamed to report experiences of mistreatment, due also to the crucial sensitivity of the phenomenon.

Although our review investigated only the specific Italian context of elder abuse, it provides information on types and risk factors related to the phenomenon which can apply also to other countries, and this can contribute to raise general awareness on this crucial topic, especially in States (such as Italy) where very limited information has been made available so far on the issue by the international literature. Our study also provides information which may be applicable for use by policy makers, clinicians and researchers at the European and country levels for monitoring and preventing abuse, and also for awareness and educational campaigns. Following these considerations, our manuscript, due to its focus on “understanding for prevention” of elder abuse, may also be of more general/common interest to an international readership.

Limitations of the reviewed studies

In addition to the highlighted lack of systematic, comparable data able to capture a nationwide picture of elder abuse in

Italy, the few reviewed studies presented some limitations that reduce their relevance and generalizability. Firstly, they adopted various definitions of elder abuse and related figures-types-categories of abuse, thus the lack of a uniform definition made comparisons between findings very difficult and so results should be considered with caution. This caution may be extended also to what is meant by "elder”, because the different studies considered different populations-target groups, and used different age restrictions, whereas a more accurate definition of “older people” should consider other factors besides the number of years, e.g. levels of autonomy, quality of life, retirement status.

Secondly, different sampling methods-recruitment procedures (random sample or small convenience), study designs

(general population or focused on women only; sporadic inclusion of institutional settings and of neglect), measurements and instruments (standardized or not) were used. Sometimes values/percentages were also differently calculated, i.e. as prevalence of episodes for the total population as in ABUEL study by Soares et al., 2010, or conversely as distribution of cases-various types of abuse on total of detected “crimes”, as in the AUSER Survey on

2011. All these “technical” differences are likely to have impacted on findings and lead to biased results, and with different non-response rates and underestimations, which in any case were higher than usually found in research, given the sensitivity of the topic. In particular, the further use of small sample sizes, with low representativeness of the population, does not allow for generalization of the findings. Moreover, some studies adopted a design which did not include the marginalised population of people with Dementia, whose impaired mental capacity prevented them from participating and from answering the questions in the instrument used for the survey (Soares et al., 2010), whereas conversely dementia is well known in literature as a specific risk factor of elder abuse (Cooper, Selwood, & Livingston,

16 2008). Thirdly, the studies examined different time-frames (abuse experienced in the last year or lifetime history of abuse). Fourthly, due to a focus on local settings, in some cases studies were limited to a single Italian city or Region.

Finally, there was often limited information collected about perpetrators. Summing up, all these differences make a full comparison of results on elder abuse from various studies, which sometimes also showed different prevalence rates, extremely hard, Therefore, generalisation of findings, which are not always confident, and a nationwide representativeness of these studies are almost impossible to assert, given the lack or scarcity of some important information on the phenomenon.

CONCLUSION

Over the last ten years the abuse and neglect of vulnerable older adults has received and increasing recognition, as a crucial social problem of concern, in many European countries, but a clear identification of elder mistreatment still remains problematic (Penhale, 2010). Additionally, in Italy elder abuse represents a crucial societal issue, but it still remains a ‘social taboo’ hard to tackle in the debate about the aging population, and it is hidden both within familial boundaries and institutions. Older adults usually avoid discussion about such a sensitive issue and do not report episodes of mistreatment, especially when depending on relatives for care and support. Underreporting is also due to a lack of awareness and understanding of what is elder abuse, and in Italy this is connected to the lack of an agreed- official and acceptable or uniform definition of the phenomenon, which makes comparison of research findings very difficult. In turn this problem has consequences for the prevention and identification of elder abuse, and for the formulation of interventions by policy makers. Increased awareness and understanding of elder abuse can help in the recognition of violent, abusive and neglectful behaviours and in reacting to them more appropriately (Werner,

Eisikovits, & Buchbinder, 2005). However traditional cultural values such as family solidarity-support, and cultural differences among generations, influence definitions and awareness of elder abuse, but it is crucial to clearly and preventively inform older people about what elder abuse “could” be. Once consensus over the definition of this particular vulnerability of older people has been established, and there is a common standardized operational definition of this “neglected” phenomenon, it will be easier to understand and to identify the key risk factors and the possible hard consequences which often occur due to a failure of early detection, in addition to the implementation of dedicated guidelines and support provided by health-social services to the victims.

In any case, in Italy the lack of an appropriate legal framework for dealing with elder mistreatment represents a major challenge (Molinelli et al., 2011). There are only a few articles of the Penal Code which consider crimes against older people as general crimes against disadvantaged groups (art. 570: Violation of obligations to family care; art. 571: Abuse of means of correction or discipline; art. 572: Mistreatment of family members or children; art. 591: Neglect of minors

17 or incapacitated persons) (Melchiorre, Chiatti, & Lamura, 2012). Moreover, in Italy there is also a lack of national policy on elder abuse. There are some local initiatives (e.g. helplines) but these are not specifically dedicated to tackle the issue of elder abuse. In addition, research on elder abuse still seems to be at an early stage of development in Italy, despite the fact that this problem may affect a large proportion of the population (older people aged 65+ constituting over 20%, and those aged 80+ 6%, of the Italian population,) (ISTAT, 2012).

More systematic future research is therefore urgently needed to determine the dynamics of elder abuse and neglect in

Italy, in order to identify which measures and public policies might be most effective to prevent it, and in particular for monitoring the quality of care in residential settings and to support informal caregivers in assisting their dependent older relatives.

Acknowledgements

This article is partly drawn from a report prepared in 2008-2009 by Maria Gabriella Melchiorre and Giovanni Lamura for a European review on ‘High quality care for the older people and the prevention of elder abuse’, Commissioned by the European Commission, Negotiated procedure/Contract no: VT/2007/065, coordinated by Bridget Penhale,

University of East Anglia (UEA), School of Nursing and Midwifery, UK. We acknowledge the European Commission for the funding received in order to undertake the study. The views expressed in this paper are those of the authors and are not necessarily representative of the European Commission.

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