How older persons explain why they became victims of abuse

Abstract

Background: elder abuse greatly impacts the quality of life of older individuals. Prevalence rates range from 3 to 30% depending on the definition used. Only about a dozen studies have explored how older victims themselves experience and explain abuse. It is essential that healthcare professionals understand the perceptions of older victims as they are among the most important groups to handle and report abuse.

Design: a qualitative study on the perceptions and experiences of victims of elder abuse was conducted using in-depth semi-structured interviews.

Setting: abused individuals living independently, in residential care facilities and nursing homes.

Subjects: six males and 11 females aged 63–90 years.

Results: the main causes of abuse identified by older victims themselves were mutual dependency between victim and perpetrator, power and control imbalances, loneliness and a marginalised social position of older persons. Effects of abuse included negative feelings, physical and psychological distress, a change of personal norms and values, changed perspectives on money and low self-efficacy. These differential effects depended upon the types of abuse experienced and the relationship with the perpetrator. Coping strategies mentioned by victims were seeking informal or professional help and using self-help strategies.

Conclusion: older victims perceive abuse differently depending on the expected acceptability of the type(s) of abuse experienced and the anticipated stigma associated with the perpetrator involved. The effects and chosen coping strategies are influenced by these considerations and therewith also influence their help-seeking behaviour. Healthcare professionals are encouraged to use these findings in practice to prevent, detect and intervene in elder abuse.

older people, elder abuse, causes, effects, coping strategies, qualitative research

Introduction

Descriptions of elder abuse from the victim's own perspective are not prominent in the existing literature. The majority of research on elder abuse focuses on theories of elder abuse, definitions, prevalence, types, risk factors and prevention and intervention strategies [1–12]. Remarkably, within this growing body of literature only a few dozen studies explore and discuss elder abuse from the ‘eye of the beholder’ [4, 13, 14, 15, 18, 19, 23, 24, 25, 26]. Even fewer studies have researched the conceptualisation of victims, and current knowledge relies to a great extent on individual case studies [16, 18–23].

The insights of victims themselves are especially important to take into account, to develop appropriate preventive measures, to establish methods for detection and to initiate fitting interventions as our understanding of the occurrence of abuse should align with explanations of victims. For older individuals, healthcare professionals are among the most important groups to identify and to report elder abuse, but few cases are reported [27–29].

On 1 July 2013, the Reporting Code Domestic Violence and Child Abuse Act came into effect in the Netherlands. Professionals who suspect that violence is occurring must adhere to a reporting code. There is no mandatory reporting in the Netherlands. The Advice and Support Centre for Domestic Violence was the main institute for reporting elder abuse. On 1 January 2015, it merged with the Advice and Reporting Centre for Child Abuse and Neglect and became named Safe at Home. It supports victims, perpetrators, professionals and concerned bystanders.

To enhance the understanding of healthcare professionals and their modes of detection and intervention, this article will shed light on how older victims experience, perceive and explain the process of abuse. We discuss the victims' ideas about the causes, consequences and effects of abuse, ways of coping with abuse and explore how victims process what happened to them.

Methods

A qualitative study on the perceptions and experiences of elder abuse was conducted in the Netherlands among abused older persons. The method of data collection was in-depth semi-structured interviews with 6 older men and 11 older women in the age range of 63–90 years. The average age was 80 years. Thirteen participants lived independently and four lived in an institutional care. The male respondents were formerly employed in the field of finance, accounting or management. Four out of the 11 female participants had earlier worked as tailors or housekeepers; others had no professional experience and did not attend higher education. Participants in this research were fully informed of the purpose of the interviews and their contribution was completely voluntary. Respondents received a notebook as a token of appreciation.

In the development of the core concepts of this study, we used the definition of the WHO (2002) as a reference: ‘Elder abuse is a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person’. All concepts, however, were open, and treated in an iterative way, that is depending on how the individuals involved in this study conceptualised the concepts (or not) we re-conceptualised them.

As the aim of the current study was to study perspectives of victims of abuse, we wanted to keep the concept of elder abuse open, which allowed the participants to express their own perceptions and experiences. The interaction between data, concept and theory remained iterative throughout the study. Given the text-based data we collected, we used a hermeneutic approach. We primarily used an inductive approach of grounded theory that implies that theory is built from data or grounded in the data [30].

Six victims of elder abuse were recruited through advertisements in freely distributed local newspapers in Haarlem, Leiden and Alphen aan de Rijn. According to the Central Bureau of Statistics (1 January 2015), the population of this region has 385,603 inhabitants, among which 60,700 are older than 65 years. Eleven were contacted after referral through elder advisors and welfare managers who work in healthcare institutions or support centres of domestic violence. The main inclusion criterion was experience with any type of abuse. Some weeks before the interview, the contact persons or the researcher A1 asked older victims to participate in the study. When interested, A1 contacted them personally. After a full explanation of the research purpose by phone, appointments were made for a place and time to meet as chosen by the interviewee. All the interviews were conducted at the places older persons were living. Before the interview, voluntary informed consent was obtained (or signed) in which confidentiality and anonymity were guaranteed and permission for recording was given by all interviewees. In this article, we have used arbitrary numbers (from 1 to 17) for all informants. All participants were considered to be cognitively intact and had the capacity to consent to involvement in the study. We did not ask for permission from the medical ethical committee because it did not concern patients, but we did adhere to the ethical standards as subscribed by the designated professional associations of anthropologists, in particular the American Anthropological Association (AAA) and European Association of Social Anthropologists (EASA). The anthropological researchers have ethical obligations and a responsibility to whom they work with and whose lives and cultures they study, which means they do not harm the safety, dignity or privacy of the people with whom they work, conduct research on, or who might reasonably be thought to be affected by their research.

The in-depth interviews were held with the support of an interview guide as developed by A1 and A3. The interview guide was based on existing research literature on elder abuse (see Supplementary data, Appendix S3, available in Age and Ageing online). Five pilot interviews were held with non-abused older persons and middle-aged individuals prior to the present study, after that the interview guide was adjusted where necessary. In line with semi-structured interviewing techniques, open questions were formulated and adjusted while interviewing to enhance applicability, understanding and clarity for individual respondents. The interviews lasted 2–4 h and took place between September 2012 and December 2013.

The grounded theory approach was used to analyse the data. The interviews were transcribed verbatim. The transcripts were carefully read and studied and then coded. We used NVivo, a computer software program for qualitative data analysis. We used inductive and primarily ‘open’ coding that allows generating theory that is grounded in the data and enables emergence of understanding from the close study and constant comparison of the data. In vivo coding was also used whenever open coding could not capture the interpretive meaning of the concept. In discussion with the co-investigator A3, the list of codes was developed. After studying relations between concepts, codes were further used for developing more abstract themes resulting in the main categories that are discussed in this article. This method of analysis gives the opportunity to explore different ways in which respondents explain their experiences and feelings; it also allows unexpected topics, thoughts and ideas to arise that would be neglected with a predetermined questionnaire.

Results

Table 1 provides details on the abusive situations experienced by our interviewees. In our study, physical abuse encompassed intentional infliction of pain ranging from hitting, kicking to pushing. Psychological abuse included threatening, manipulating, insulting, blaming, offending, intimidation and humiliation. Financial abuse involved spending the older person's money without their knowledge or permission, scams and extortion. Neglect included denying the older person adequate care, nutrition, clothing or a clean environment.

Table 1.

Description of abusive situations of victims

Type(s) of abuse	Age	Gender	Relationship perpetrator/victim	Duration of abuse	Seeking help	Coping strategy
Physical abuse	82	Male	Caregiver	3 months	After a couple of weeks	Professional help
Psychological abuse	65	Female	Partner	6 months	After 2–3 months	Informal help
Psychological abuse	72	Female	Partner	Abusive situation was ongoing		Self-help
Psychological abuse	74	Female	Granddaughter	2–3 months	After 1 month	Professional help, self-help
Financial abuse	76	Female	Son	4–5 months	After 1–2 months	Professional help
Financial abuse	80	Female	Acquaintance	Abusive situation was ongoing	After 2–3 months	Informal help, professional help, self-help
Neglect	90	Male	Partner	Abusive situation was ongoing		Self-help
Neglect	79	Female	Grandson	10 months	After 4–5 months	Informal help
Psychological and financial abuse	81	Male	Previously unfamiliar person	2 years	After a couple of months	Professional help, self-help
Psychological and financial abuse	84	Male	Daughter	Abusive situation was ongoing	After a couple of months	Self-help, professional help
Psychological and financial abuse	80	Female	Neighbour	8–9 months	After 2–3 months	Professional help
Psychological and financial abuse	77	Female	Granddaughter	One year	After 3–4 months	Professional help, informal help
Psychological and financial abuse	63	Male	Acquaintance	Abusive situation was ongoing	After 1–2 months	Professional help, self-help
Psychological and financial abuse	75	Female	Acquaintance	Abusive situation was ongoing		Professional help, self-help
Psychological and financial abuse	79	Male	Neighbour	Abusive situation was ongoing	After 2 months	Professional help, informal help, self-help
Psychological, financial and physical abuse	78	Female	Son	One year	After 6–7 months	Professional help, informal help and self-help
Neglect and psychological abuse	90	Female	Son	More than 1 year	After 4–5 months	Professional help, informal help

Here we describe the main findings; these include causes, effects and consequences and coping strategies. In the Supplementary data available in Age and Ageing online, Appendix S1, we present two illustrative case studies to allow further understanding.

Causes of abuse

I am dependent on care, I need help with some activities at home, also with finance, groceries … that does not put you in a strong and advantageous position, you are much more vulnerable and can easily become a victim … (interviewee 1)

I feel redundant because our society perceives me as such. I feel like there is a label ‘too old’ in this society (interviewee 2)

One of the first elements in self-explanations of older victims was the cause of abuse. Our participants mentioned various factors, among them loneliness and social isolation, dependency of victim and perpetrator, power and control imbalance and the position of older persons in society. In many cases, victims felt lonely and socially excluded, because they were isolated by their perpetrators from the outside world. Lost autonomy and vulnerability made older victims feel powerless and dependent which correlates and supports their perceived position in the current society of social isolation and exclusion.

Although there are not many studies that point to the relationship between loneliness and elder abuse, our interviewees felt that loneliness and social isolation increased their risk of becoming a victim of abuse. For instance, they often relied heavily on the perpetrator and did not have frequent contact with other relatives or friends, resulting in a limited social network. In retrospect, some described feeling trapped. Being lonely and socially isolated made them feel defenceless, dependent and more vulnerable as they felt they needed the ongoing care and assistance from the perpetrator. These elements were perceived as contributing to the abuse since there was a lack of alternative contacts to turn to when the abusive situation occurred.

The victims interviewed described dependency on others for care—assistance with the activities of daily living, help and support—as a factor that makes older persons vulnerable to abuse. At the same time, they felt that the perpetrator was also dependent on them, for instance for living or financial support and victims felt responsible to support the perpetrator, even while they were mistreated. According to the interviewees, such a mutual dependency increases the risk of abuse because there is a delicate balance that may shift towards the perpetrator taking control. This shift created the ground for abuse to occur according to our interviewees. Victims detailed they felt they could not control the situation or were losing control over it, and therefore became powerless. Mutual dependency was closely related to power and control inequalities in relations between victim and perpetrator.

The role of mutual dependency was more prominent in cases where victims experienced different types of abuse simultaneously and with psychological abuse and especially when the perpetrator was a close family member. These factors contributed to victims being more dependent on and more encompassed by the relation with their perpetrators. Because of the close relationship and with less space to manoeuvre, they felt they had ‘allowed’ abuse to occur and continue. In cases of financial abuse, mutual dependency was based on the financial dependency of the perpetrator (needing money) and dependency on care of the victim and on the contact of the perpetrator with the victim.

Our interviewees felt that feeling powerless and losing control over the situation triggered violence from the abuser's side. Combined with dependency and vulnerability of older victims, this increased their feeling of being helpless and redundant. The powerlessness they experienced influenced power and control feelings of the perpetrator. At the same time, some victims felt that abuse could occur rather as a response to a lack of power of the perpetrator and an inability to deal with the situation concerned, for instance, when victims did not grant the wishes of the perpetrator or were unable to meet their requests, or when perpetrators felt overwhelmed by the care burden. Victims thought that by abusing an older person the perpetrator tried to restore power and control, ultimately regaining power in the relationship or could be seen as quite the opposite as acts of powerlessness.

Finally, our interviewees felt that the marginal position of older persons in our society had an impact on abusive situations. In this regard, interviewees mentioned notions such as disrespect and devaluation of older persons. Perceptions of older victims as being useless, unnecessary and ‘too old’ (as sensitively expressed by interviewee 2 above) were part of their explanations for the occurrence of abuse in their life. They felt neglected by society and not taken seriously. Our participants concluded that changes in societal norms and values and the negative image of old age had changed the position of older persons. They reasoned that this created a culture of acceptance and permissiveness for using violence against older persons.

Effects of elder abuse

This experience is shameful and humiliating. I felt stressed and at the same time desperate … (interviewee 3)

Times are changing, values and norms in society are different. It was normal to help your parents they said, but now my children are not doing this for me. They see me as not worth it, ‘as rubbish’. I was treated like trash that has no feelings or thoughts (interviewee 4)

According to the interviewees, the experience of abuse has various consequences, which we analysed as associated with the type(s) of abuse, but also with the relationship with the perpetrator. Foremost, and rather independent of type and perpetrator, were psychological effects once becoming a victim of abuse. These included feelings of shame, helplessness, humiliation, fear and anxiety resulting in feelings of stress and depression. Older persons felt desperate, frustrated, hopelessness and distress due to their lack of ability to change the situation.

Related to these feelings were that victims blamed themselves, resulting in low feelings of self-worth. For victims, it was difficult to comprehend and accept that trusted individuals, especially in the case of relatives, were the abusers. This breach of trust not only placed shame on the perpetrator, but also on the abused for ‘letting it happen’, as one of the interviewees stated who had experienced psychological abuse with a family member. Older persons believed that they had contributed in some way or another to the abuse and were to blame.

Within the scope of physical effects, in the present study we have understood this as both the physical effects of abuse itself, and health problems encountered during or after abuse. Older victims brought up health issues especially in context to the stress or anxiety they had experienced during or in the aftermath of the abuse. The physical complaints they mentioned included continuous stomach ache, incontinence, sleep problems and loss of appetite.

Victims suffering from financial abuse described that this changed their perceptions about money. They became more watchful and meticulous with money and valuable items than before. They believed this attitude could protect them from future abuse. Saving money gave them some feeling of security and certainty.

Some of the interviewees, in particular those who were abused by non-relatives, noted that the abuse had changed their norms and values; they distrusted acts of kindness, were wary of good intentions and were sceptical of fairness of others. They were more cautious because they felt betrayed and deceived. Losing trust in people led to stress and frustration, and for some of them also to depression. Changes in norms and values that occurred with this—and as a result of abuse—had a negative impact on their notion of certainty in approaching (daily) life, as well as their psychological well-being, as these norms and values were important and represented a fundamental basis in their lives. They felt ‘empty’ as they had lost something intrinsic to their being.

The interviewees often reported, implicitly and explicitly, a low self-perception and consequently a decrease in self-efficacy, especially in cases in which they had trusted non-relatives. Victims of abuse used self-descriptors such as ‘rubbish’, ‘stupid’ or ‘idiot’. These notions created a sustained, negative image about themselves. As a result of feelings of incompetence and the denunciation of themselves, older persons also experienced difficulties in decision-making. This was especially prominent in cases of psychological abuse as this type of abuse caused interviewees to question their own capabilities. Some of the older victims had difficulty in assessing what they wanted, sometimes they described being reluctant to suggest or follow-up on ideas. Such behaviours evoked further irritation among the perpetrator and often led to more abuse.

Coping strategies

I've made a survival plan for myself. I have to do everything possible to be able to deal with the abuse and to keep living … I'm trying to keep myself busy: reading walking a lot, cycling … It helps (interviewee 5)

I needed to deal with the situation. I was trying to seek help; I called public health service, the support center for domestic violence. They were open to help … My relatives also offered their support and that meant a lot to me … (interviewee 6)

Older victims used different coping strategies. Some relied on themselves (self-help), others sought help and support from family members and friends (informal help) or from different institutions (professional help) among which were public health services, non-profit organisations and advice and support centres for domestic violence. Often interviewees used several coping strategies simultaneously (see Table 1). None of our informants sought help from health professionals from the cure and care sector such as a physician or (neighbourhood) nurse. Most of the victims described asking for help when the abuse had reached an unbearable point for them and seeking help seemed to be the only way out. They felt forced to change something, to stop the abuse when the pain became intolerable. They waited until the last moment because they were afraid to lose contact with the perpetrator or were simply scared or ashamed to tell someone about the abuse or to ask for help. The interviewees who sought professional help experienced various types of abuse simultaneously, and in most cases, the perpetrators were family members (children, partners) or close friends. Informal help was sought when victims experienced psychological abuse and neglect and perpetrators were also close family members (see Table 1). When a close family member was involved in the abusive situation the period of abuse before asking for help, for as far as can be distilled from this small sample, was reported to be longer. Victims felt ashamed and described how they anticipated denunciation by the community for having close relatives involved and they also wished to protect those relatives. Suffering from financial abuse was the clear exception to this pattern; even the involvement of a close relative was not a strong barrier for seeking external help. The interviewees felt that financial abuse is a more widespread and therefor more publically discussed type of abuse. Interviewees expressed that financial abuse was considered ‘normal’ and easier to talk about. It is thus less shameful to share your experiences with others and seek help—outsiders would understand. Victims felt that it was a clear criminal offence and most of them had heard similar stories before.

Other interviewees used a different strategy, which we designate ‘self-help’. They tried to continue their lives and overcome the negative effects by keeping themselves busy with hobbies, work and relaxation techniques. Unlike the older victims who sought help from professionals or family and friends, these interviewees thought that they could deal with the abuse and its effects on their own. Some adhered to this strategy because they were afraid to lose contact with the perpetrator, or, were afraid to suffer even more abuse if they sought help from outsiders. These victims typically experienced psychological abuse or neglect. The perpetrators in these cases were family members (see Table 1).

There were respondents who used different coping strategies at the same time. They asked for professional help and/or informal help from family or friends and used self-help strategies to deal with abuse. These respondents experienced psychological, financial abuse or a combination of various types of abuse and perpetrators involved were family members or acquaintances (Table 1).

Discussion

The findings reported here illustrate the process of abuse as it is experienced and perceived by older victims. We inferred the main causes of abuse, explained why it tends to continue according to victims, and reported on how it affected their well-being and self-perceptions. Finally, we discussed strategies victims used to deal with the abusive situation.

Other studies that have reported on perceptions and experiences of older victims of abuse are in line with our findings. A qualitative study among abused older women also found that an imbalance in power and control was an important factor in the occurrence of abuse [16]. The mutual dependency between victim and perpetrator that comes to the fore in our study has also been identified earlier [35, 36]. We additionally identified that the negative image of ‘being old’ influenced the victims' perception of themselves. This also led victims to conclude that abuse is somehow permitted by the norms in current society and contributing to abusive circumstances.

There is also another facet that surfaced from the stories of the older victims. In retrospect, they felt that they did not stand up for themselves and allowed perpetrators to continue the abuse. They described themselves as being compliant with the abusive situation, which sometimes provoked even more violence. Other older victims felt that the abusive situation was beyond their control and influence. These reactions of older persons resemble the phenomenon of ‘learned helplessness’ in which victims of abuse feel helpless to change abuse, refrain from doing anything and accept any treatment that is also observed in cases of violence against women [37, 38].

The differential effects of abuse we found in our study have been reported earlier [13, 16, 18, 24]. Quite similar to our study, it was found that older victims reported psychological effects such as grief, anger, disappointment, psychological distress, anxiety, depression, feelings of social inappropriateness, social isolation, deteriorating physical health, loss of independence and financial loss [15, 24, 39]. In contrast to other studies, we found two effects of abuse that have not been commonly identified: a change in values and norms and a lower self-efficacy. The importance of these effects to older persons is connected to the role of norms and values in the lives of older persons, and is influenced by the position of older people in current society and their self-perceptions on their own value in this society. Perceived negative images of being too old, unnecessary and unvalued influenced their perception of themselves, created negative feelings and low self-confidence, and also led to the belief that abuse is influenced by current society. The found effects might be the result of the qualitative design of the study that allowed participants to freely express their feelings and to freely detail on the consequences they experienced.

Although the relationship between the different types of abuse and the nature of the relationship with the perpetrators was less clearly acknowledged, similar to our study previous studies have shown that older persons used informal and professional help to cope with abuse [15, 17]. Survival strategies identified among older women in Australia, such as blocking out the violence, and putting energy into another activity, resemble the self-help strategies found in current study [17].

Implications and recommendations

Healthcare professionals can use the findings from this study to detect and address elder abuse. Next to the commonly identified signs of abuse, they could pay closer attention to mutual dependency between victim and perpetrator in socially isolated situations to detect high-risk situations for abuse. Healthcare professionals can play a vital role in the prevention and detection of abuse as older individuals frequently visit healthcare institutions. Moreover, special attention should be given to the social situation of a patient, especially relationships with informal caregivers and relatives and socially isolated situations in which the perpetrator has decisional power, is overruling and perhaps overly protective and the older individuals seem to experience low self-esteem and has limited say in decisions. Together, picking up these kinds of signals could help in the (early) identification of abuse.

In addition to the well-identified signs of abuse [31], it would be advisable for healthcare professionals to consider a possibly abusive relationship, especially in cases of unexplained physical or depressive symptoms among elderly and decreased feelings of self-esteem and self-efficacy. The latter might present as difficulties in making decisions and lack of motivation to engage in activities.

The differences in help-seeking strategies we observe seem to be associated with distinct feelings of shame and anticipated humiliation that are related to the different types of abuse and the relation between victim and perpetrator. Self-blame is an important element in this rationale. Healthcare professionals could aid older victims by discussing abuse in related, more neutral, terms (e.g. harm, unhappy, not well) and by discussing elder abuse more openly to reduce the stigma associated with most types of abuse (e.g. have you felt hurt or harmed by someone in your environment recently? instead of asking directly about abuse). If suspicions of abuse cannot (yet) be discussed, a sign of attention can already help the victim, and alternative measures (e.g. expanding the social or care network) rather than direct intervention might alleviate the situation and support victims.

One of the possibilities to deal with lower self-esteem and self-efficacy among older victims is the organisation of support groups for victims that will be coached and led by an experienced professional or peer. Older persons would be able to share their experiences, coping strategies used and receive feedback and advice from other participants who have had similar experiences. The participation in these groups could enhance members' sense of empowerment and belonging, which might itself have positive effects on self-esteem and mental health [40]. These groups could include face-to-face conversations, empowerment training and psychological support. Moreover, these support groups may be used together with peer support or advocacy schemes that are already practised in other countries. Additionally, trainings directed at assertiveness and self-support strategies can help older victims to deal with abuse and reduced self-efficacy we identified in this study.

Limitations

The sample size in this study may be considered relatively small. Some of the findings can, therefore, not be generalised to the whole population of abused older individuals; however, our primary aim was to identify variables that play a role in the experience of abuse. We did so by an in-depth exploration of the understanding of the experiences of older victims of abuse. Although the empirical features of the variables might be different in different cases, we did identify variables that influence the process of abuse according to victims' experiences.

We used only one method of data collection to identify variables, mainly because in-depth interviewing allowed the older victims to express themselves unhampered. Although triangulation of methods is always preferable, the enduring sensitivity of the topic and the accompanying shame prevented the use of alternative methods, such as focus groups, to further delve into the self-explanations of older victims.

One of the possible limitations was self-selection bias; although we used an implicit inclusion criteria (participants were cognitively intact), we did not use any other exclusion criteria. Owing to the sensitivity and complexity of the researched topic, it was difficult to reach respondents and that is why all the victims who agreed to participate in the study were included. Considering that the aim was to find variables of importance, the selection of informants does not impact the identified variables themselves.

The participants of this study were not followed up longitudinally, which excluded the possibility to check how they currently felt and how their life changed over time. Therefore, it is difficult to talk about the prolonged effects of abuse. Future studies could look into this.

Conclusion

The process of abuse as experienced and explained by older victims included the description of the main causes of abuse identified as dependency, power and control imbalance, loneliness and the marginal position of older persons in society. We found psychological, physical, financial and material effects, loss of norms and values, and low self-efficacy as consequences of abuse. Coping strategies used by older victims included professional, informal and self-help. The effects of abuse and chosen coping strategies are influenced by the expected acceptability of the type(s) of abuse and the expected stigma associated with the perpetrators involved. Healthcare professionals are encouraged to use these findings in practice and help to detect, prevent and intervene in elder abuse. Paying close attention to mutual dependency of victim and perpetrator in socially isolated situations, unexplained physical symptoms, feelings of depression and low self-efficacy next to the commonly identified signs of abuse and discussing these signs in unobtrusive terms might enhance the identification of abuse by healthcare professionals and assist them in the development of appropriate interventions.

Key points

• Victims see the causes of elder abuse as stemming from mutual dependency, power and control imbalances, loneliness and a marginal social position of older persons.

• Effects of abuse include psychological, physical, material and financial effects, loss of norms and values and low self-efficacy.

• Coping strategies included seeking informal or professional help and self-help strategies.

• Healthcare professionals should pay close attention to mutual dependency of victim and perpetrator that results in increased isolation, unexplained physical symptoms, feelings of depression and low self-efficacy.

• Discuss abuse in neutral terms but openly with their abused patients.

Conflicts of interest

None declared.

Acknowledgements

The authors thank the older victims for their participation in the study and their willingness to share their stories.