Risk and protective factors

Risk factors

Mistreatment of older adults is a complex multifactorial problem that is part of relational dynamics that go beyond the victim-perpetrator relationship per se, because the problem is influenced by social, political, and cultural factors, as well as factors associated with older adults themselves, the people who mistreat them, and the environment in which the mistreatment occurs [31–34]. As shown in Table 1

on the different types of mistreatment, the perpetrator is not necessarily a natural person, but can be an organization.

To be effective, measures designed to put a stop to situations of mistreatment must be based first and foremost on knowledge of the associated risk factors. The state of knowledge on risk factors not only varies depending on the type of mistreatment concerned [31,35], but is influenced by the definitions, theoretical framework and methodology used to conduct studies [36]. Consequently, it is difficult to draw up a clear, comprehensive and final list of all the risk factors for mistreatment. In any case, such an approach would be counterproductive, for the list would probably be very long and therefore not sufficiently specific to inform solutions. During international scientific symposiums in the past two years, researchers have suggested that risk factors for mistreatment should be refined according to the type of mistreatment involved and the dynamics of the relationship between the mistreated person and the person or organizational context that mistreats. Future scientific work can thus be expected to follow this approach.

Several studies [32,36,38] have used the categories of risk factors developed by the National Research Council [37]. The quality of the scientific evidence for each category of factors strengthens their power for explaining mistreatment situations [36]⁴. Three categories have been identified:

1. Risk factors validated by substantial evidence⁵;
2. Possible risk factors⁶;
3. Contested risk factors⁷.

Table 2 presents the three categories of risk factors for older adult mistreatment defined by the National Research Council. The risk factors are classified according to whether they are related to the individual at risk of mistreatment or to aspects of the individual’s environment. Since the publication of this classification in 2003, other studies including literature reviews [32,36] have enriched its results. This additional information has been included in Table 2.

Table 2 - Risk factors for mistreatment

This table highlights the extent to which knowledge about older adult mistreatment has progressed since the National Research Council first published its findings [37]. The factors based on strong scientific evidence in 2003 are still included in the list of risk factors, but others have been added in recent years. In addition, the possible and contested risk factors have been documented more fully and garnered more scientific support; they are thus questioned to a lesser extent than in the past. It should be noted that some of the factors presented in the table appear, at first glance, to be contradictory. This is the case, for example, of social isolation and a weak social network, on the one hand, and shared living arrangements, on the other. The presence of these seemingly contradictory risk factors stems from the fact that they are not associated with the same types of mistreatment [31,32,36]. Lastly, it should also be noted that the impact of life-long violence or neglect on the risk of being a victim of mistreatment later in life is increasingly well documented [31,32]. More longitudinal studies would add to our knowledge in this area.

Factors specific to the person and factors specific to the environment

As shown in Table 2, the number of environmental risk factors validated by substantial evidence seems to be greater than the number of individual risk factors validated in this way. This is consistent with recent research data indicating that environmental risk factors are better predictors of mistreatment of older adults than individual risk factors are [41]. This observation could guide professionals in their clinical activities, for it might be easier for them to act on environmental factors than on certain individual ones (e.g. dementia, state of health, sex, ethnic background, etc.) in their efforts to counter mistreatment. It could also be of use to public decision-makers who have to design intervention programs and implement action plans using an evidence-based approach.

Most of the findings presented thus far concern mistreatment of older adults living at home. However, certain risk factors are related more specifically to residential facilities, such as residential and long-term care centres (CHSLDs). The organization of daily life in such facilities (e.g. care schedules, meal times, etc.) can lead to a loss of freedom for residents [42], while the kind of group living arrangements typically found there can cause negative resident-to-resident interactions [43]. Table 3 presents the most widely documented risk factors associated with the organization of the facilities themselves, their staff members, and the older adults who live there [44]⁸.

Table 3 - Risk factors in residential facilities

Source : Executive summary of the report La maltraitance envers les personnes aînées en milieu d’hébergement. État de situation sur sa prise en charge et mise en perspective d’une approche visant le signalement obligatoire [44].

Table 3 clearly shows that, although mistreatment may be perpetrated by staff members or even other residents in residential facilities, it can also occur within the broader context of organizational mistreatment⁹.

Multifactorial nature of mistreatment

The definition of mistreatment provided in section 1 explains that mistreatment situations are relational in nature, that is, they occur in contexts where there is an expectation of trust. As mentioned earlier, the characteristics of the victim (or the person at risk of mistreatment), the perpetrator (or the person who may be at risk of mistreating), and the older person’s living environment can all have an impact on the incidence of mistreatment. The social, political, and cultural context in which mistreatment occurs can also be an influential variable.

At the social level, ageism towards older adults is reflected by negative stereotypes [52], which are shown to create a breeding ground for mistreatment [53,54]. For example, in residential facilities, ageism can have a negative impact on professionals’ interactions with residents, as well as negative consequences [55].

At the cultural level, mistreatment studies in cultural communities have shown that there are multiple perceptions of mistreatment [32]. For example, the Québec government’s perception of mistreatment may be different from that of a person who belongs, for example, to a Spanish-speaking [56] or Aboriginal community [57]. Moreover, being an immigrant or a refugee can also have an impact on the way a person views mistreatment [58]. Therefore, people who work with seniors from diverse cultural communities should adopt a culturally sensitive approach.

Protective factors

“Protective factors are characteristics specific to the person … or to their environment … that tend to reduce the risk of developing certain problems such as mistreatment” [8,36]. That being said, they are not the opposite of risk factors¹⁰, and their presence does not mean that risk factors are absent¹¹.

Since few studies have focused on protective factors, it is impossible at this time to provide a nuanced assessment.

The Guide de référence pour contrer la maltraitance envers les personnes aînées [13], developed in Québec, nonetheless suggests a number of possible protective factors specific to the person or to the environment¹². They are presented in Table 4. 

Table 4 - Protective factors

Source : Guide de référence pour contrer la maltraitance envers les personnes aînées, 2^nd edition [13].