International Review of Psychiatry

ISSN: 0954-0261 (Print) 1369-1627 (Online) Journal homepage: http://www.tandfonline.com/loi/iirp20

Domestic violence and mental health in older

adults

Lucy Knight & Marianne Hester

To cite this article: Lucy Knight & Marianne Hester (2016) Domestic violence and
mental health in older adults, International Review of Psychiatry, 28:5, 464-474, DOI:
10.1080/09540261.2016.1215294

To link to this article: http://dx.doi.org/10.1080/09540261.2016.1215294

Published online: 26 Aug 2016.

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INTERNATIONAL REVIEW OF PSYCHIATRY, 2016
VOL. 28, NO. 5, 464–474
http://dx.doi.org/10.1080/09540261.2016.1215294

REVIEW ARTICLE

Domestic violence and mental health in older adults

Lucy Knighta and Marianne Hesterb
a
Somerset Partnership NHS Foundation Trust, Bridgwater, UK; bSchool for Policy Studies, University of Bristol, Bristol, UK

ABSTRACT ARTICLE HISTORY

Domestic violence affects every age group and is present throughout the life span, but, while Received 7 March 2016
the mental health impact of domestic violence is clearly established in working age adults, less Revised 24 June 2016
is known about the nature and impact of domestic violence among older adults. This review, Accepted 18 July 2016
therefore, aimed to synthesize findings on the prevalence, nature, and impact of domestic vio- Published online 25 August
2016
lence among older adults, and its identification and management. Electronic searches were con-
ducted of Medline, PsycINFO, Cinahl, and Embase to identify studies reporting on the mental KEYWORDS
health and domestic violence in older adults. Findings suggested that, although prevalence fig- Domestic; violence; abuse;
ures are variable, the likely lifetime prevalence for women over the age of 65 is between interpersonal; mental; older;
20–30%. Physical abuse is suggested to decrease with age, but rates of emotional abuse appear adult; health
to be stable over the lifespan. Among older adults, domestic violence is strongly associated with
physical and mental health problems, and the scarce research comparing the impact of domestic
violence across the age cohorts suggests that the physical health of older victims may be more
severely affected than younger victims. In contrast, there is evidence that older victims may
experience less psychological distress in response to domestic violence than younger victims.
Internationally, evidence on the management of domestic violence in older adults is sparse.
Findings suggest, however, that identification of domestic violence is poor among older adults,
and there are very limited options for onwards referral and support.

Introduction and set this age group within a different context when
it comes to intimate partner violence and their
Domestic violence affects every age group and is pre-
responses to it. As a result of these differences, health
sent throughout the life span, although it may mani-
services in the UK, for example, continue to be pro-
fest differently in older adults. There is evidence of
vided separately to older adults, both in mental health
the health impact of domestic violence on working
and acute medical trusts.
age adults, with high rates of physical and mental
This review, therefore, aimed to synthesize findings
health problems in both female and male victims
on the prevalence, nature, and impact of domestic vio-
(Ferari et al., 2014; Hester et al., 2015; Howard, lence among older adults, and its identification and
Trevillion, & Agnew-Davies, 2010) and male perpetra- management. In this paper we use the term domestic
tors (Hester et al., 2015). However, the impact of violence, with a specific focus on intimate partner vio-
domestic violence on older adults has been less of a lence, defined by the World Health Organization &
focus, and the research into this area is patchy and London School of Hygiene and Tropical Medicine
largely unsynthesized. The relevance of age may seem (2010, p. 18), as ‘behaviour within an intimate relation-
unclear, and, in the UK, where the focus of services ship that causes physical, sexual or psychological harm,
in some areas is on integration and ageless provisions, including acts of physical aggression, sexual coercion,
it could be argued that extrapolating the data for psychological abuse and controlling behaviours. This
younger people would be sufficient. However, those definition covers violence by both current and former
who work with older adults will be aware that there spouses and partners’. Our emphasis is on the older
are important differences between the age groups, adult population, particularly the over 65s. However, as
with older people presenting to services in different research into older adults uses varying age ranges,
ways and facing different challenges. Issues such as some of which include people from the age of 55, we
health, self-care at home, financial security, inherit- have included studies reporting on adults younger than
ance, and loneliness are paramount for older people, 65 in order to match the body of research available to

CONTACT Lucy Knight [email protected]

ß 2016 Institute of Psychiatry
 INTERNATIONAL REVIEW OF PSYCHIATRY 465

us. We searched Medline, PsycINFO, Cinahl, and their caregivers, Buttell (1999) discusses the relatively
Embase for studies that reported qualitative or quanti- separate areas of spousal abuse and elder abuse and
tative findings from studies of mental health and the difficulties resulting from the development of sep-
domestic violence in older adults. Only English lan- arate bodies of knowledge in these areas. This paper
guage papers were included. Searches were supple- was published over 16 years ago, but these issues
mented by citation tracking and from the results of a remain pertinent and relevant today.
systematic review being concurrently undertaken into
domestic abuse and dementia (McCausland, Knight,
The nature of domestic violence in
Page, & Trevillion, 2016).
older adults
In all age groups, domestic violence may involve
Prevalence of domestic violence across
more emotional and psychological abuse than phys-
the lifespan
ical violence (Office for National Statistics (ONS),
Surveys suggest the lifetime prevalence for domestic 2013/2014). It is thought that domestic violence is
violence in the over 60s may be anything from 5.36% even more emotional and less physical in older
(Zink, Fisher, Regan, & Pabst, 2005) to 26.5% adults (Band-Winterstein & Eisikovits, 2009; Roberto,
(Bonomi et al., 2007). In a recent national survey in McPherson, & Brossoie, 2014). This theory is sup-
Germany, St€ ockl and Penhale (2015) reported that ported by a recent survey in Germany of 7257
current intimate partner prevalence for all types of women of all ages by St€ ockl and Penhale (2015).
intimate partner violence was 27% for women over They reported that, in older women over the age of
the age of 65, 30% for women aged 50–65, and 33% 65, 1% described past year physical or sexual vio-
for women aged 16–49. In 2013 the World Health lence. This compared to 8% of women aged 16–49,
Organization published a report in which they state and 3% of women aged 50–65. These figures demon-
that the global lifetime prevalence of intimate partner strate a reduction in rates of physical violence over
violence among ever partnered women is 30.0%. They the years, and provide a useful comparison between
break down the prevalence data by age, and for older and younger women, which is lacking in other
women aged 65–69 they report that the global preva- studies. In the same study, other types of abuse
lence is 22.2%. They do not have any data for women remained more stable across the lifespan, with 13%
over the age of 70. They comment, however, that of women in all age groups reporting emotional
most of the data does not include information for abuse in their current relationship, and 21% of
women over the age of 49, and, therefore, this data women in all age groups reporting controlling behav-
should not be interpreted as meaning that older iour. There was a very slight increase in economic
women experience lower levels of intimate partner abuse, from 12% in women aged 16–49 to 13% in
violence, but rather that less is known about this age women over the age of 65. This reduction in phys-
group (WHO, 2013). ical violence may, in part, reflect the physiological
changes in the brain and its development over the
lifespan. The frontal lobes and associated neuronal
Domestic violence and elder abuse
tracts provide the tone for reducing violent behav-
Intimate partner domestic abuse in older adults sits iour through impulse control, and they are not
awkwardly within and alongside the sphere of elder matured until well into a persons 20s (Lebel &
abuse, and research into elder abuse includes couples Beaulieu, 2011). One would expect rates of physical
where violence has been longstanding, but does not violence would decrease as a result of this brain
always identify these couples and considers them as a development.
discrete sub-set. Within the elder abuse literature Some of the variation in prevalence of psycho-
there are frequent references to a link between pre- logical abuse between studies may be due to the dif-
existing relationship difficulties and severity of elder ferent definitions and questions asked, as well as the
abuse, but this group of older people are not sepa- abuse being defined over different timescales. Some
rated into a sub-group at any point for separate ana- scales include one-off episodes of being criticized,
lysis (Buttell, 1999; Compton, Flanagan, & Gregg, whereas others require a higher threshold of harmful
1997; Cooper, 2009; Coyne, Reichman, & Berbig, behaviours. The rates of physical violence in St€ ockl
1993; Yan, 2014). and Penhales survey compare to the 8% found in the
In his paper on the relationship between spouse Crime Survey England and Wales 2013/2014 (ONS
abuse and the maltreatment of dementia sufferers by 2013/2014) for all adults.
466 L. KNIGHT AND M. HESTER

Ill health, dementia, and domestic violence at vulnerable and have less ability to defend themselves
the end of the lifespan from physical attack and verbal assaults. They can be
neglected and denied food and water if they are
Health and dementia are key issues within the consid-
immobile. They can also have continence needs which
erations of older people and intimate partner violence.
can be used as a vehicle for abuse. Introducing new
Older people suffer more from ill health, and this will
demands and needs into a relationship which is abu-
impact their view of themselves, their needs within
sive can change the system in unpredictable ways, and
relationships, and their responses to mistreatment
these things are issues for victims and perpetrators of
from others. Dementia is more common as we age,
abuse alike. People who have been victimized over
and with an ageing population it is projected that
long periods of time may struggle to provide care for
there will be 1 million people with dementia in the
the perpetrators of the abuse.
UK by 2021 (Alzheimer’s Society, 2013). The elder
Equally, it may not be surprising if perpetrators
abuse literature has looked at the link between
make poor carers, and, as mentioned earlier, a poor
dementia and elder abuse, and findings indicate that pre-morbid relationship is a strong predictor for elder
patients with dementia are more at risk of elder abuse abuse (Buttell, 1999; Compton et al., 1997; Cooper,
than those without (Dong, Simon, Rajan, & Evans, 2009; Coyne et al., 1993; Yan, 2014). In our explora-
2011; Dong, Simon, Beck, & Evans, 2014; Sasaki et al., tory study regarding 20 couples with a history of
2006; Vida, Monks, & Des Rosiers, 2002). Dong et al. domestic violence (Knight & Hester, 2014) we found
(2014), in their study of 143 dementia sufferers, found that providing care for each other after the onset of
that the risk of elder mistreatment increased with dementia was too challenging for more than half of
every small decrease in cognitive function. The lowest couples. In this study, there were often safeguarding
tertiles in global cognitive function were associated concerns raised about the quality of care provided
with an odds ratio of 2.71 for elder mistreatment. both by the perpetrators of domestic violence and by
Within the elder abuse literature, the intimate part- the victims.
ner violence population is not often differentiated. In
some studies it is possible to identify when abuse is
occurring at the hands of an intimate partner or close The impact of non-physical domestic violence
family member, but this is not always the case, and by in older adults
definition elder abuse can be perpetrated by anyone Assumptions that the impact and severity of abuse
involved in the patient’s care, including paid carers. will be increased with the presence of physical and
When trying to identify that group of patients who sexual violence need to be questioned. Victims of all
have experienced domestic violence prior to the devel- ages report that non-physical abuse is often more
opment of dementia, there is often little or no refer- harmful than physical violence, with younger women
ence to the previous relationship quality. When it is reporting that emotional abuse has a higher negative
described, it is often couched in vague terms such as impact on them than physical abuse (Marshall, 1996).
‘poor pre-morbid relationship’ (Compton et al., 1997), In their qualitative research on older women who
which does not allow us to determine the definite experience non-physical abuse in the US, Seff,
presence of pre-morbid domestic violence. Beaulaurier, and Newman (2008) reported that
In our recent systematic review of domestic abuse women described the criminal justice system as being
and dementia, we concluded that family member unable to respond to emotional abuse in the way that
domestic violence may be more likely in patients with they can respond to physical abuse. They talked about
dementia than patients without dementia. We identi- the impact of abuse on their confidence and how
fied only two studies of elder abuse that recorded the quickly and comprehensively non-physical abuse
relationship status of the perpetrators of abuse, and could affect their lives, so that they ended up unable
also referred to a control group which could provide to make any decisions for themselves.
a comparative risk of domestic abuse. The pooled These women reported that non-physical abuse was
odds ratio for risk of domestic abuse with dementia as bad or worse than physical abuse, because of the
was 2.68, implying that having dementia may increase nature of it. One woman said that ‘when it comes out
the risk of domestic violence from a family member of the mouth it comes straight from the heart …
(McCausland et al., 2016). Words hurt more than a beating’ (Seff et al., 2008,
Part of this increase could be due to ill health and p. 366); another is documented as saying ‘they don’t
dementia causing an increase in frailty and depend- know sometimes mentally it’s even more damaging.
ence on others for support. People who are unwell are That’s what’s hidden, that’s what never comes out’ ‘a
 INTERNATIONAL REVIEW OF PSYCHIATRY 467

punch, a wound, is going to heal … But the psycho- divorce or separation. There are significant questions
logical abuse terminates you … many women don’t being raised by emerging research regarding the long-
know it, but it is the worse crime’ (Seff et al., 2008, term impact of exposure to trauma, and the possibility
p. 367). that this may lead to premature mortality. This ques-
This view, that psychological, non-physical abuse tion is not investigated in any of the available research
could be more damaging than physical violence, is relating to domestic violence in older adults, which do
supported by the findings of Mouton, Rovi, Furniss, not report on mortality rates.
and Lasser (1999). They surveyed 257 women between
the ages 50–79. They asked questions to detect
Domestic violence and mental health among
domestic violence and reported that 31.9% had expe-
older adults
rienced domestic violence at some point in their life.
Women who had been threatened had lower mental The research into mental health sequelae of domestic
component summary (MCS) scores as well as lower violence focuses on many different types of disorder,
‘Role-Emotional’ scores (these are markers of mental varying from specific diagnosed depression (Fisher &
health status) compared to women who hadn’t. The Regan, 2006; Hester et al., 2015; WHO, 2013; Wilke &
association between poor mental health and women Vinton, 2005; Zink et al., 2005), to vaguer measures
who had experienced only physical assault without of psychological distress (Mouton et al., 1999, 2010;
threats was less marked, implying that it is the pres- St€
ockl & Penhale, 2015). However, whichever way it is
ence of threat or psychological harm that has the measured or categorized, research focusing on the
greatest impact. In this survey women who had been mental health of older adults experiencing domestic
threatened also reported generally poorer physical violence shows an increase when compared to older
health and increased pain when compared to women adults in non-violent relationships. There are also sig-
who had not been threatened. nificant effects on physical health measures across the
In a later survey by Mouton, Rodabough, Rovi, board (Fisher & Regan, 2006; Hester et al., 2015;
Brzyski, and Katerndahl (2010), 93,676 women aged McGarry, 2011; Mouton et al., 1999, 2010; St€ ockl &
50–79 were investigated in the US. They reported that Penhale, 2015; Zink et al., 2005).
11.1% of respondents described some form of physical The most commonly measured mental health prob-
or verbal abuse. As part of their survey they asked lems are depression and anxiety. Fisher and Regan
people to complete the mental component summary (2006) investigated this in 842 women over the age of
(MCS) from the RAND 36 item health survey. They 60 in Indiana, Ohio, and Kentucky. They found sig-
found that, where verbal abuse was involved in the nificantly raised odds in women who were identified
abuse pattern, there was a significant negative impact as abuse victims of suffering from depression and
on the MCS scores, whether physical violence was anxiety, as well as digestive problems and chronic
involved or not. pain. Overall, women who identified as abuse victims
These findings support the idea that non-physical also reported a significantly higher number of other
abuse is, at least as, if not more harmful than physical health conditions compared to non-abused women.
abuse, and has significant wide reaching psychological However, the greatest impact in this study was on
effects on those who experience it. depression and anxiety, where the adjusted odds ratio
was 2.24 in the abused women.
In their review of post-menopausal women,
The impact of domestic violence on the
Mouton et al. (2010) also found that, as well as a
wellbeing and mental health of older adults
lower mental component summary (MCS) score,
The emerging picture of the impact on older adults women who were abused had significantly increased
experiencing domestic violence is of strong links depressive symptomatology, and worse scores on all
between poor physical health in various domains, as mental health sub-sets, compared with non-abused
well as increased rates of depression and anxiety. older women. Similarly, a prevalence study in 2005 by
These are coupled with the possibility that, for older Zink et al. surveyed older women about health and
adults, their psychosocial functioning is less impaired mental health. They showed a trend towards increased
than might be assumed from the co-morbidities. This morbidity in women who identified themselves as vic-
may be a function of increasing wisdom with age, as tims, and there was significantly increased prevalence
well as being related to the way that domestic violence for depression and anxiety. Here, 49.1% of women
is viewed within that age cohort, and the relative mer- who identified as being victims reported depression or
its of remaining married and coping, vs the shame of anxiety, compared with 30.4% of women who did not
468 L. KNIGHT AND M. HESTER

identify as victims. Victims also reported higher earlier adult life in some way predisposes people to
prevalence of chronic pain, and strokes or nerve prob- responding to later trauma with higher levels of dis-
lems, but these did not reach significance. tress, and greater functional impairment than for
those who do not have the earlier history of trauma.
Similarly, McGarry, Simpson, and Mansour (2010), in
Domestic violence and addiction among
a qualitative study researching how domestic abuse
older adults
affects the well-being of older women, reported that
The link between addiction and domestic violence is women experienced psychological problems at the
well established in working age adults (WHO, 2013), time of the abuse, but also later in life. These included
but we found that there is much less information panic attacks and acute anxiety. A woman described
regarding this in older adults. Wilke and Vinton her experiences: ‘The long-term impact on my health
(2005) showed that women over the age of 45 were has been depression … I had it then when all that
more likely to drink alcohol daily than the younger was going on and now for 10 years … nearly 12 years’
women; however, this did not include the over 65s. In (McGarry et al., 2010, p. 35). This study suggests the
their research on 38 women in abusive relationships long-term impact of domestic violence, and that ear-
between the age of 54–90, Zink, Jacobson, Regan, lier trauma might lead to long lasting vulnerability to
Fisher, and Pabst (2006) found that 39% reported psychological distress, even after the abuse has come
substance abuse problems. However, in general, to an end. The long-term effects of trauma exposure
research on older adults has tended to focus on phys- were also explored in the recent review by Lohr et al.
ical health problems alongside the mental health (2015), which investigated the association between
issues, and quantitative studies on addiction are PTSD and premature senescence. They included 32
scarce. In their qualitative study, Lazenbatt, Devaney, studies in a quantitative synthesis, and found an asso-
and Gildea (2013) report that the women described ciation between post-traumatic stress disorder (PTSD)
severe depression and anxiety with treatment with exposure and an increased risk of multiple physical
tranquilisers, antidepressants, and sedatives over many health problems, premature death, and an increased
decades. Six women in this study were being treated risk of dementia. They concluded that PTSD acceler-
for addiction to tranquilisers. One woman said ‘My ates the ageing process and that exposure to traumatic
husband (a general practitioner) got his medical part- events has a whole body effect, with changes in both
ner to prescribe Valium for me in the 1970s and I am the physiology and psychology of those exposed to
still taking it. I know I am addicted to it’. This paper trauma. The link between PTSD in early life and the
emphasized the problems with addiction that the later onset of dementia is a significant concern for
women faced, including alcohol misuse ‘My children women experiencing domestic violence, and would
see me as an “old drunk”. I feel ashamed’ (Lazenbatt constitute another burden for older women who have
et al., 2013, p. 30). been traumatized within violent relationships during
their adult life.
Long-term impacts of domestic violence among
older adults Comparing the impact of domestic violence on
younger vs older women
What also emerges from the research body is a link
between exposure to domestic violence and long- The studies described above compared the prevalence
standing psychological vulnerabilities and difficulties. of mental health problems between abused and non-
This link is explored in the study undertaken by abused older women, but did not compare the impact
Cisler, Begle, Amstadter, and Acierno (2012) in 2012. of domestic violence on younger women compared
In their study on mistreatment and self-reported emo- with older women. In their paper ‘The Nature and
tional symptoms they used survey data on 5777 adults Impact of domestic violence across age cohorts’,
aged 60 and over, to investigate the impact of elder Wilke and Vinton (2005) undertook a secondary ana-
abuse. In this study, they found that the impact of lysis of the US national violence against women sur-
recent elder abuse was greatly increased with regards vey which was undertaken in 1995 and 1996. This
to emotional and functional impairment, in respond- survey used telephone interviews of 16 000 women
ents with a history of prior traumatic events. These across the US; 398 women reported being victims of
participants were more vulnerable to current mistreat- domestic violence within 5 years of the interview.
ment than those who did not report prior traumatic These women were split into age groups 18–29,
events. This suggests that trauma experienced in 30–44, and 45 and older. This showed significant
 INTERNATIONAL REVIEW OF PSYCHIATRY 469

differences between these age cohorts for many varia- back on one’s life with a sense of closure and com-
bles. A chronic mental health condition was reported pleteness, and then to accept death without fear.
by 14.8% of the older age cohort, compared to 3.2% Erikson believed that, if at this later point in life we
by the younger age cohorts. Older women also see our lives as unproductive or feel that we did not
reported higher rates of chronic disease, antidepres- accomplish our life goals, we can become despairing,
sant use, and other psychotropic drugs. However, on leading to depression and hopelessness.
psychosocial functioning measures, there was either It is not hard to imagine how older women who
no difference, or the older women performed slightly have experienced long-term abuse might find this psy-
better. chosocial crisis hard to navigate. The bitterness and
St€
ockl and Penhale (2015) also compared age disappointment could be overwhelming, and this
cohorts, and they included older women in a separate seems to be embodied in the statement quoted by a
cohort. They interviewed 4448 women aged 16–49, woman in the study by Band-Winterstein and
2030 women aged 50–65, and 779 women aged 66–86 Eisikovits (2009), ‘Fifty years isn’t enough? I am a sick
who were identified in a national survey in Germany. woman, and he doesn’t give me any rest … He can’t
The interview process began with face-to-face inter- do anything to me anymore. I said that the social
views and then involved a written questionnaire com- worker should take him to a nursing home. I hate
pleted alone. They identified different types of him. I can’t look at him. I won’t forgive’ (p. 173).
intimate partner abuse, including physical or sexual Band-Winterstein and Eisikovits (2009) looked at
intimate partner violence, emotional abuse, economic individual older women and men who had experi-
abuse, and controlling behaviour. They then calculated enced domestic violence through most of their adult
odds ratios for different health symptoms for the lives, and listened to their stories. With this study, the
three groups of women. These odds ratios were calcu- themes emerged of finding things harder over time,
lated against non-abused women of the same age. For
and feeling less resilient to abuse as they aged. Older
‘strong psychological problems’ the odds ratio is 2.96
women spoke of the double burden of poor health
for women aged 16–49, 2.45 for women aged 50–65,
and intimate partner violence and how they could not
and 2.53 for the older women. These figures are all
bear it any longer.
significantly raised compared to non-abused women,
Older adults experience all the same psychological
but are similar across the age cohorts. For psycho-
effects as younger adults as a result of domestic vio-
somatic symptoms the oldest age group showed the
lence; the wearing down of their confidence, the
lowest odds ratio, and this was also true for ‘mild psy-
restriction of opportunities for success and personal
chological problems’. This supports the findings in the
growth, and at times severe social isolation. However,
paper by Wilke and Vinton (2005), which showed a
for older adults there are also added psychological
better reported level of everyday psychological func-
burdens. They may have been subjected to domestic
tioning by older women exposed to domestic violence,
whilst also finding that they are experiencing higher violence over many years, for some the whole of their
levels of mental health problems. It is hard to under- adult life. They may also experience the loss of hope
stand these findings, as more severe mental health of change or apology. In the small exploratory study
problems are normally associated with poorer psycho- by Knight and Hester (2014) looking at domestic
social functioning. abuse and dementia, one older woman who had expe-
rienced abuse throughout her married life recounted
how she was very disappointed in herself for return-
Understanding the impact of domestic violence on ing to the marriage after leaving. She said that ‘she
older adults returned in order to hear him say how much he loved
When thinking about the psychological impact of her and the children and to acknowledge to them all
domestic violence across the life span we need to con- how much he had damaged them. She is still waiting
sider the psychological challenges and tasks facing for this to happen’. ‘I was just waiting for him to
older adults. In the late 20th century Erik Erikson come home and say sorry … and he never did’
(Erikson, 1994) proposed a series of psychosocial cri- (Knight & Hester, 2014, p. 12). For this woman the
ses that are foremost at different times across different difficulties were compounded when she developed
ages. For adults over the age of 65 he proposed that dementia and became dependent on her husband for
the psychological crisis was ‘integrity vs despair’. His everyday support.
theory suggested that success in this life stage would Another theme that arose in this study was that of
lead to wisdom which results from being able to look loneliness, and the fear of loneliness. One older
470 L. KNIGHT AND M. HESTER

woman reported that ‘I guess my fear of being alone damage done within violent relationships (Creamer &
is so strong that it’s … I’m willing to tolerate any- Parslow, 2008). When considering the mental health
thing to avoid it’ (Zink, Regan, Jacobsen, & Pabst, of older adults, disorders that are highly affected by
2003, p. 1438). Loneliness is not confined to older emotional states and stress are also important. These
people, but the perception is often that older people would often be described as ‘psychosomatic’ or
are less likely to find new relationships (Zink et al., ‘psychological’, and would include disorders such as
2003). Loneliness is the subject of a large body of fibromyalgia, irritable bowel, and chronic pain. When
research, and is linked to poorer mental health out- evaluating the impact of domestic violence on older
comes (Ong, Uchino, & Wethington, 2016), and lone- adults, these other disorders should also be taken into
liness can be experienced within a violent relationship account.
as a factor that increases tension and conflict (Ron &
Lowenstein, 1999). In their qualitative study on older Older adults, mental health, and perpetration
women living and coping with domestic violence, of domestic violence
Lazenbatt et al. (2013) quoted a woman as saying ‘My
life is not happy or full of family and friends. I feel The literature investigating the link between perpetrat-
totally alone. My husband hated my family and ing domestic violence and mental health is scant.
friends and systematically removed them from my Oram, Trevillion, Khalifeh, Feder, and Howard (2013)
life. I am now angry that I allowed him to do this. A published a systematic review and meta analysis of
lonely life into old age leaves me with dread’ (p. 30). psychiatric disorder and the perpetration of partner
violence. They found that, although data was scarce, a
A sense of being trapped and unable to leave may
history of psychiatric disorder increased the odds of
worsen the emotional and psychological harm that
perpetrating domestic violence against a partner to
results from the abusive relationship. Older adults
between 2–3 for both men and women with psychi-
may feel less able to leave abusive relationships, and
atric diagnoses. Their review did not differentiate per-
are less likely to access voluntary sector support to
petrators or victims by age. Shorey, Febres, Brasfield,
help them cope with the difficulties and plan for their
and Stuart (2012) investigated the prevalence of men-
safety (Beaulaurier, Seff, Newman, & Dunlop, 2007;
tal health problems in younger men arrested for
McGarry, Simpson, & Hinsliff-Smith, 2012). They
domestic abuse and court-referred to Rhode Island
may feel guilty about leaving a now frail, albeit abu-
batterer intervention programmes. The average age of
sive, partner who may rely on them for care and sup-
men in this sample was 33. They found depressive
port with everyday living. Zink et al. (2003) published symptoms positively correlated with severity of psy-
a qualitative study looking at reasons why older chological abuse perpetrated, i.e, the more severe the
women remain in abusive relationships, one woman psychological abuse perpetrated, the more severe the
stated ‘I can’t let him go to the dogs’ (p. 1437). Older depressive symptoms reported. This link was also true
victims may also face financial restraints that can limit for anxiety disorders amongst the men.
their sense that they can leave, as they may want to Hester et al. (2015) investigated the link between
safeguard an inheritance, or have only a small pension perpetrating negative behaviours and health in men in
(Tetterton & Farnsworth, 2011). primary care. They found that perpetrating negative
So older people experiencing domestic violence behaviours, including perpetrating domestic violence,
struggle with many of the same psychological chal- were associated with an increase in the odds of anx-
lenges as their younger counterparts, but also face iety and depressive symptoms. The association was
other hurdles specific to their age, such as poor also present for men who reported being victims of
health, loss of role with retirement, length of time negative behaviours and those who reported both per-
exposed to domestic violence, and the challenge of petrating and being victims. This sample included
facing the end of their life. men who were over the age of 65, but does not report
The combination of the physical and psychological on these older men as a sub-group. Despite the lack
burdens of domestic violence that occur at any age of research into older adults and perpetration of
with the increased physical vulnerability that occurs domestic violence, the evidence from younger adults
with increasing age would seem likely to result in a points to a clear association between poor mental
high impact of domestic violence in older adults. One health and perpetration. This is likely to persist into
of the questions here is whether the increasing wis- later life, but the other issues that arise in later life
dom and psychological resilience that is reported to may change some of the features of perpetration and
occur with increasing age might offset any of the its impact.
 INTERNATIONAL REVIEW OF PSYCHIATRY 471

A striking finding in the qualitative study by Band- three older people came forward for the study.
Winterstein and Eisikovits (2009) involving older McGarry et al. (2012) identified that the focus of pro-
adults, is how men who perpetrate violence have psy- vision of services was generally on younger adults,
chological processes that minimize the violence, mostly in the age range 25–45. They spoke to volun-
decontextualize their spouses’ responses to their abuse, tary sector providers and quote one Independent
and, through strongly held opinions, achieve a view of Domestic Violence Advisor as saying ‘if you are a
themselves, the perpetrators, as victims. When 70 year old woman or man and you’re offered refuge,
describing the view of one of the men in the study, I don’t think I’d go!’ (McGarry et al., 2012, p. 18).
who had perpetrated abuse over his adult life, the A social worker in the same study is quoted as
author stated that ‘he perceives himself as non-violent, saying
as a person who would never even hurt an animal, The refuges that we have … the nearest ones that
and as a victim of his wife’s emotional abuse. She is I know of are all for younger women and they often
described as a person who constantly attempts to have children there and they’re totally unsuitable for
cause him harm’ (Band-Winterstein & Eisikovits, older women … we have used residential care, again
2009, p. 172). This highlights the difficulty with per- its not the most ideal place … its not the most pleas-
ception of perpetration within violent relationships, ant environment for someone who’s otherwise well
which is also echoed in the literature on younger age but is having to cope with a separation from a hus-
groups, although the generational issues may also pro- band who she’s been with an awful long time
vide a particular context for perpetrators seeing them- (McGarry et al., 2012, p. 25).
selves as victimized. They also highlight the overlap between elder abuse
and domestic abuse in the older age group, and how
Identification and management of domestic this can be confusing to all parties. The previous
violence in older adults domestic abuse can be relatively hidden within the
current situation, where one party may be caring for
Internationally there is little evidence that any coun-
the other due to recent physical health problems or
tries are delivering a cohesive response to domestic
dementia.
abuse in later life. The ‘Elder abuse and neglect in the
In our exploratory study (Knight & Hester, 2014),
European Union, UN Open-ended Working Group
none of the couples were supported by the voluntary
on Ageing, 2012’ stated that, with regards to elder
sector. One couple had been referred to the local
abuse ‘there is no comprehensive EU-wide response
domestic abuse services, but had been redirected to
on this issue, especially one of a binding nature’
Age UK (a UK based charity for older adults) for sup-
(Georgantzi, 2012, p. 4). Equally in the US there are a
variety of agencies involved in responding to late life port. Age UK had not responded to this request, and
domestic abuse, but the provision and range of these the patient had given up trying to get help at this
varies around the country (Aravanis, 2006). Because point. Identification of abuse in our study had
of the lack of information about international strat- occurred primarily as a result of physical abuse being
egies for managing domestic violence in older adults, reported, and there was no evidence of patients or
this section focuses on UK services. carers being asked about domestic abuse directly as
Over time considerable provision of largely non- part of a normal assessment. Within the older adult
governmental, voluntary sector, services for domestic psychiatry services across the UK, the issues of
abuse has developed in the UK, but targeted mainly domestic abuse remain poorly recognized and routine
towards working age adults and the protection of chil- screening questions relating to domestic violence are
dren. Compared to working age adults, older adults not normal practice. Patients are increasingly asked
may have a different view of themselves and of mar- about domestic abuse in some general practices, but it
riage, and this affects their likelihood of raising issues is not clear if this includes over 65s (Feder et al.,
of domestic violence and abuse with others, and of 2011).
seeking help with these relationship issues. The identi- Another theme that emerged in our research was
fication of older adults who are experiencing domestic the issue of older people not recognizing themselves
abuse, and who are wanting help or support is chal- as victims of domestic abuse, instead they tended to
lenging. McGarry et al. (2012), in their report on ser- minimize the difficulties and conflict within their rela-
vice responses to domestic abuse affecting older tionships. Identifying and supporting people within
people, sought the views of older adults in violent abusive relationships is much more difficult when the
relationships and, despite extensive outreach, only people involved are not acknowledging the difficulties,
472 L. KNIGHT AND M. HESTER

and are not seeking help. Where they might want to they have the knowledge and skills necessary for
seek help there are numerous barriers to this, such as working with older people.
frailty, guilt about leaving partners who might be In their article ‘Intimate partner violence in late
unwell themselves, financial issues, and family worries life: a review of the empirical literature’, Roberto et al.
(Beaulaurier et al., 2007). (2014) discussed the theoretical frameworks, concep-
This raises the question of how we should be sup- tual themes, and methodological processes that cut
porting older adults who are in violent abusive rela- across research in this area. They also highlighted the
tionships. We need to be mindful to respect their difficulties with a lack of theoretical understanding
views and position, and their right to continue within behind interventions and management strategies, and
lifelong relationships despite the apparently harmful suggest that the way forward for this group of individ-
effects of that relationship. We need to be cautious uals is to be managed within multidisciplinary teams.
about determining the extent of that harm when view-
ing the relationship from the outside. Also, we need Conclusions
to reflect carefully on the harm of intervening, and
Findings suggest that between 20–30% of older adults,
how this would be viewed within the marriage or
the majority of whom are women, experience or have
partnership concerned and by the family of those
experienced domestic violence throughout their life-
involved. As we have seen earlier in this paper, older
time. Although in the over 65s there is less physical
adults report lower levels of psychological harm as a violence, the rates of non-physical abuse seem to be
result of domestic violence than younger adults stable across the lifespan. The effects of the ongoing
(St€ockl & Penhale, 2015; Wilke & Vinton, 2005). non-physical abuse are significant, and range from
Introducing standard questions on domestic abuse higher rates of mental health problems to increased
at assessment within mental health services could pose reports of poor physical health. The review also raises
some added difficulties compared to with younger findings regarding the long-term impact of exposure to
adults. As an old age psychiatrist, my experience is that trauma, and the possibility that this may lead to pre-
older adults tend to attend mental health clinics with mature ageing, premature mortality, and dementia.
their partners and may be reluctant to disclose abuse This could have significant consequences for this
in the presence of their spouse or partner (Tetterton & population of women, as well as other groups of people
Farnsworth 2011). In their guidance on domestic vio- experiencing trauma such as the armed forces. The
lence, NICE (2014) suggests that staff do not talk to association between perpetration and mental health
partners together about relational issues. issues is also apparent, but this literature is very scarce
Then there is the issue of what to do with the in older adults. Evidence on managing domestic vio-
information gathered. There are no clear referral path- lence in older adults is also lacking, tending to focus
ways for domestic violence in older adults, and, as we on interventions that are developed without the
have seen before, the voluntary sector in the UK do strength and depth of understanding needed behind
not routinely offer age-appropriate interventions and those interventions to make them effective and useful
support. Older women are much less likely to access for older adults. The review, therefore, points to mul-
interventions such as refuges, and perpetrator pro- tiple areas for future research into older adults and
grammes are largely aimed at younger adults. There is abuse. These include how health professionals recog-
also the problem that the effectiveness of these types nize domestic violence in older adults, investigating
of interventions remains uncertain, and research is robust referral pathways for individuals and couples
ongoing (Ellsberg et al., 2015). Once the abuse is dis- once they have been identified and the further
closed, what actions should be taken by the health or investigation of the possible links between trauma
social care worker is unclear. and dementia. Current research into older adults
Social care services and more specifically adult safe- rarely differentiates between intimate partner abuse,
guarding services (a service within UK social care familial domestic abuse, and wider network abuse
services that safeguards vulnerable adults) tend to be (elder abuse). Also lacking in older adult domestic vio-
the avenue for managing any significant identified lence, is research into personal factors that mitigate the
risks relating to domestic abuse within older adult effects of abuse: who copes better and why?
relationships in the UK. McGarry et al. (2012) recom-
mend that safeguarding and domestic abuse services Disclosure statement
develop co-operative and collaborative multi-agency The authors report no conflicts of interest. The authors alone
working, and that the voluntary sector ensure that are responsible for the content and writing of the paper.
 INTERNATIONAL REVIEW OF PSYCHIATRY 473

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