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


Specific to the mistreated person
(intrinsic factors)

Specific to the environment
(extrinsic factors)

Risk factors validated by substantial evidence

  • Dementia [32,36,37,39];
  • Low income [32].
  • Social isolation and weak social network [31,32,34,36,37];
  • Shared living arrangement [32,36,37,40];
  • Characteristics of the person who mistreats:
    • Mental health problems;
    • Hostility;
    • Alcohol dependence;
    • Dependence on the older adult [36,37];
    • Caregiver burden and stress [32];
    • Cognitive decline and dementia [32].

Possible risk factors

  • Sex (female) [32,36,37];
  • Personality traits (hostility, passive or avoidant ways of coping) [36,37];
  • Ethnic background [32,36,37,39];
  • Age [32];
  • Civil status [32];
  • Level of education [32].
  • Living alone [32,34];
  • Relationship between the mistreated person and the person who mistreats (spouses) [36,37].

Contested risk factors

  • Physical impairments, poor health [32,36,37].


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

Factors associated with the organization of facilities

  • Lack or shortage of staff [10,45–47];
  • Heavy workload preventing professionals from delivering quality care in a timely manner [48–50].

Factors associated with staff members

  • Inadequate knowledge and limited training [10,45,51];
  • Personal problems, including a history of domestic violence, mental illness, or use of drugs or alcohol [45,51];
  • Stress, emotional fatigue, or burnout [10,45,51];
  • Negative attitude toward older adults in general and residents in particular, or toward working with this type of clientele [10,51].

Factors associated with the person or his or her network of family and friends

  • Social isolation or few or no visitors from outside the facility [10,45].

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

Protective factors specific to the person

Protective factors specific to the environment


  • e.g. self-knowledge, sense of responsibility, resourcefulness, etc.

Ability to seek help:

  • e.g. being able to confide in others, make oneself understood, take advice, etc.

Emotional competencies:

  • e.g. ability to cope with events and make sense of them, adoption of strategies for dealing with stress, etc.

Social participation:

  • e.g. sense of belonging, social inclusion, social support, feeling of social competence, etc.

Ability to learn about oneself and society:

  • e.g. having autonomy, being able to make choices, set personal goals, pursue lifelong learning, and find time to engage in hobbies, etc.

Good lifestyle habits:

  • e.g. ability to relax, laugh, build positive and beneficial relationships with family and friends, etc.


  • e.g. an appropriate network of available people, a legal representative available if necessary, a network adapted to the needs of older adults, etc.


  • e.g. a safe living environment adapted to the needs of older adults and free from ageism and social exclusion, etc.

Financial situation:

  • e.g. adequate available income, various means in place to secure belongings and money, etc.

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

  1. The studies identified have certain limitations, such as the fact that they are not based on longitudinal research designs aimed at determining the causal relationship between the different factors and situations of mistreatment. Therefore, the scientific quality of these factors and their reliability for indicating the presence of mistreatment depends on the preponderance of studies reaching the same findings. In other words, the results are based on unanimous or near-unanimous support from the studies identified [36].
  2. These are factors that have been validated by many studies and for which there seems to be a scientific consensus.
  3. These are factors that have been documented, but for which there is no consensus, particularly because the results are contradictory, or the studies were limited in scope. 
  4. These are factors for which there is little scientific evidence. They are identified by certain studies as being associated with increased risk for the emergence of mistreatment situations, but they need to be validated more extensively before they can be considered proven risk factors [36,27].
  5. For more information, see Beaulieu, M. and Leboeuf, R. (May 4, 2016). Synthèse exécutive du rapport Beaulieu, M., Manseau-Young, M.-E., Pelletier, C. et Spencer, C. (12 janvier 2015). 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. Submitted to the Québec government’s Secrétariat aux aînés, 27 p. This document can be accessed free of charge at: www.maltraitancedesaines.com.
  6. Organizational mistreatment: [TRANSLATION] “Any prejudicial situation created or tolerated by organizational procedure in private, public, or community organizations providing any type of care or service, and which compromises a person’s ability to exercise his or her rights and freedoms.” [12].
  7. For example, dementia is a known risk factor, but the absence of dementia cannot automatically be considered a protective factor [8].
  8. For example, an older adult may have dementia or be assisted by a caregiver with an alcohol dependence problem (risk factors) but have good self-esteem and a social network including other adequate caregivers (protective factors).
  9. Since this information is based on data provided by the Canadian Mental Health Association – Québec Branch (2015), these protective factors are not specific to older adults.