Bullying in Old Age: A Qualitative Study on Older Adults’ Perceptions About Being Bullied

Introduction and Literature Review

Rising average life expectancy and improved health and well-being resources has allowed people today to live better and longer (Mathers et al., 2015; World Health Organization [WHO], 2015). However, there are concerns about how the social implications of these population changes may underline maladaptive relational phenomena involving more vulnerable populations (Krug et al., 2002; Wolf et al., 2002), such as episodes of violence against older adults (Krug et al., 2002). Although there is little data on bullying in old age, bullying is estimated to affect between 10% and 20% of older adults (Manacchio, 2019). According to a recent study by the WHO, among 53 European countries, Portugal is one of the five countries with most violence against older adults, reporting a rate of 39% of victims being older adults, and also highlighting situations of serious abuse and bullying (WHO, 2015).

Studying the phenomena of bullying in old age is becoming increasingly important (Zsoldos et al., 2014). Although often associated with school contexts, bullying can occur in a variety of other contexts and in different age groups (McDonald et al., 2015). Bullying can be defined as the practice of violent behavior with physical, psychological, and/or social consequences, characterized mainly by three components: repeating over a significant period; intentional (not accidental); and occurring within relationships dominated by an imbalance of power (imbalance by status or force; Walsh et al., 2011).

Although bullying can often involve abuse, and both concepts imply aggression, they constitute different entities (R. P. Bonifas, 2015). In abuse, victims are usually vulnerable and dependent (e.g., functional, financial) on the offender, while in bullying both the offender and the victim are often vulnerable adults and the victim is not necessarily dependent on the offender (R. P. Bonifas, 2015). In older adults, bullying often occurs in social or institutional settings where differences (e.g., functional capacity) are observable (Gutman, 2012b). In the community, bullying experiences can happen in community centers or even from friends or relatives (National Center for Assisted Living [NCAL], 2017; Yon et al., 2017). In this context, bullying can take the form of stereotyped comments, offenses, and verbal aggressions, and older people practice a more adaptive and resilient approach (R. P. Bonifas, 2015; Walsh et al., 2011). Overall, the causes of bullying are complex and dependent on the age difference between victim and bully, and associated with the social and/or family dimension of both actors (MacNeil, 2002).

Violence can manifest itself in many ways, but five types are generally considered in the literature: physical, psychological, sexual, financial/material, and neglect (Naughton et al., 2010; Pillemer et al., 2016). The types of violence and their prevalence vary significantly according to the cultural and social context, and bullying events can include several types of violence (Lachs & Pillemer, 2015; NCAL, 2017; Pillemer et al., 2016).

In general, factors contributing to bullying in older adults include gender, where women are the most abused; difficulties in functional capacity, particularly when there are difficulties in mobility and greater dependence on others; poor mental health, with indicators such as high levels of depression and anxiety; and cognitive impairments, such as memory deficits (Jeon et al., 2019; Pillemer et al., 2016; Wolf et al., 2002). In addition, a poor perceived physical appearance, in particular when there is body image disturbance, less socioemotional skills (as in mismanagement of emotions), and economic issues (such as low income) can contribute directly to the occurrence of bullying (Jeon et al., 2019; Pillemer et al., 2016; Wolf et al., 2002). Likewise, ageism is often one of the factors promoting bullying, through subjects like the myth of “asexuality” in old age and the false beliefs of older adults being “useless” and “overloading” in society (Gutman, 2012b; Krug et al., 2002).

There is a marked lack of studies on bullying in older adults (McDonald et al., 2015), particularly there is a significant terminological incoherence that influences the specific study of bullying in older adults: bullying events are often indiscriminately studied in broader investigations about abuse, violence, harassment and other concepts (Walsh et al., 2011; Yon et al., 2017). However, some studies have contributed significantly to the literature in this area (Walsh et al., 2011), such as the study by Yon et al. (2017) involving 28 countries, which found that psychological abuse was the most common form of abuse (Yon et al., 2017). Within the community context, increasingly adults work until a later age and there has also been a significant occurrence of bullying in older adults in this work context, increasing the incidence of psychiatric illness (Powell, 2010; Zsoldos et al., 2014). However, there seem to be more studies focused on bullying in institutionalized elderly than in community-dwelling elderly (Lapuk, 2007; McDonald et al., 2015).

Therefore, qualitative studies can be fundamental toward making a better distinction and conceptual cohesion, and allowing a closer approach to the participant and the experience of the bullying phenomenon, which is essential in such a sensitive subject in this age range (De Donder et al., 2011). Similarly, bullying is a complex issue that requires a full understanding of the social dynamics in which older adults are involved (cross-cultural approach, which is very scarce), to isolate the specific biases of monocultural studies (Walsh et al., 2011; Zsoldos et al., 2014). These studies may contribute to a greater involvement of older adults and their families in the research processes, since most studies that have been done in this area have relied on the information given by professionals (e.g., health professionals) and not with older adults themselves or their relatives, who are the closest and most direct sources of information for older adults (C. L. Erlingsson, 2007).

Bullying studies also tend to exclude older adults with cognitive or physical deficits (Pillemer et al., 2016), and research in this area would also provide the basis for developing effective strategies to prevent and respond to this type of aggression (De Donder et al., 2011; Yon et al., 2017). Furthermore, among the few studies, most focus only on bullying in older adults in continuing/institutionalized health care (Lapuk, 2007; McDonald et al., 2015). Knowledge about older adults living in the community is valuable for planning public health resources. In this context, this study aims to analyze the perspectives of a cross-cultural sample of older adults on bullying.

Method

Recruitment and Sampling

Sample recruitment occurred through initial telephone contact, followed by a request to participate in the interview. The telephone number of the participants was obtained through the institutions older adults attend (e.g., social activity centers and senior universities) and with which the researchers had previous contacts. Data sharing rules and participant consent were respected. We obtained, through a sampling by convenience, a total of 200 Portuguese and English older community-dwelling people, in the Lisbon Metropolitan area and southern regions of the country; 195 older adults agreed to participate in the study, of which 173 were included in the final study sample, yielding an unweighted response rate of 88.7% and a weighted response rate of 92.2%. The remaining participants did not attend the interviews due to lack of availability. Exclusion criteria were cognitive level (above the Mini-Mental State Examination [MMSE] cut-off level) and being at least 65 years of age. Participants showed the following characteristics: average age of 73.5 years (SD = 4.4), with a range of 26 years (min = 65 and max = 91); more than half perceived their health as good (62.1%); a quarter were professionally active (26%); most were married (69%) or windowed (15%); and approximately 75% lived with others (see Table 1).

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Table 1.

Sample Sociodemographic Characteristics.

Characteristics	(n = 173)
Age, mean ± SD	73.5 ± 4.4
Gender, n (%)
Women	111 (64.0)
Men	62 (36.0)
Living status, n (%)
Alone	42 (24.4)
With others	131 (75.6)
Nationality, n (%)
English	94 (54.1)
Portuguese	79 (33.9)
Education n (%)
Primary school	66 (38.2)
Middle school	44 (25.4)
≥High school	63 (36.4)
Marital status n (%)
Married or cohabiting	104 (60.0)
Having a spouse or other intimate relationship	69 (40.0)
Professional status n (%)
Active	45 (25.8)
Inactive	128 (74.2)
Family annual income n (%)
≤€25,000	73 (42.1)
>€25,000	100 (57.9)
Perceived health n (%)
Good	107 (62.1)
Poor	66 (37.9)

To assess the indicators that led to the perception of being bullied, qualitative data were collected through in-depth semi-structured interviews according to the guidelines of Kallio et al. (2016). The interviews took place between December 2018 and December 2019 and were conducted in Portuguese and in English, with an average duration of approximately 40 min per interview. All interviews were conducted at the participants’ homes. The interview process took place through three main steps: (a) the contents and objectives of the study were presented to each participant, (b) the participants agreed to the objectives and gave consent to participate before starting the interviews, and (c) the interview was conducted by asking questions about three main topics: perceived causes of bullying, resources activated in bullying situations, and psychological consequences of bullying experiences. In addition, the interviewers posed additional questions throughout the interview process to better understand the bullying phenomenon in these older people. All interviewers had a short guide, identical to all interviewers, with the semi-structured interview to standardize the data collection process. During this process, we ensured that the content selected and reported by the participants had sufficient meaning and negative impact to constitute an aggressive situation characterizable as bullying. Additionally, the perceived health status was measured through a single item (“How do you perceive your health status actually?”). All interviews were audio recorded and fully transcribed. For each transcribed interview, there was first an in-depth reading, with exhaustive contact with the material for further content analysis, according to Bardin’s (1977) indications.

Considering the sensitivity and particularity of the topic of bullying in old age, the interviewers obtained previous training in the interviews to facilitate the sharing and expression of these experiences of abuse. All procedures were approved by the William James Center for Research Ethics Committee, Instituto Universitário (ISPA)—University Institute, and were in accordance with the ethical standards of the 1964 Helsinki Declaration and its subsequent amendments or comparable ethical standards.

Data Analysis

After reading the interview transcripts in depth, content analysis began with the division of information (Bardin, 1977; C. Erlingsson & Brysiewicz, 2017). First, data were condensed to generate units of meaning, which convey the main message of explicit content. Next, codes were created for the units of meaning. These facilitate the link among units of meaning, even at an operational level and without much elaboration (C. Erlingsson & Brysiewicz, 2017). The next step was to constitute a set of categories from the already constituted codes. In this process of organization, codes that referred to the same content were gathered. Category names were short and intuitive (Bardin, 1977; C. Erlingsson & Brysiewicz, 2017). The analysis process also gave rise to themes that emerged from the joining of two or more categories, through a more reflective categorization and focus on the latent content (C. Erlingsson & Brysiewicz, 2017).

Categorization was applied a posteriori (bottom-up process): the category system resulted from the analogical and progressive classification of the contents themselves. The conceptual title of each category was only defined at the end of the operation (Bardin, 1977; C. Erlingsson & Brysiewicz, 2017). Throughout the content organization procedure, the coding process followed some rules (e.g., mutually exclusive and consistently applied codes, homogeneity) to ensure the replicability and reliability of the analysis (Bardin, 1977). Finally, qualitative analysis (e.g., theoretical/empirical analysis) and quantitative analysis (e.g., descriptive statistics) were made (Bardin, 1977). Interobserver agreement was used, through at least two observers, as well as concordance statistics (e.g., Cohen’s kappa) to ensure reliability (C. Erlingsson & Brysiewicz, 2017). Cohen’s kappa scores for reliability among evaluators showed a high level of agreement (.82 < κ < .97, p < .01). Furthermore, when the information provided by the participants no longer provided new knowledge, nor contributed to the richness of the analysis, the process was stopped due to theoretical saturation (Nelson, 2016). This whole procedure was synthesized in the scheme adapted according to Bardin’s approach (1977; Figure 1).

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Figure 1.

Process of content analysis.

Results

We analyzed seven nonmutually exclusive themes that embody the diversity of narratives articulated by participants on being bullied in old age. The themes are inclusive, unless otherwise indicated. Although participants did not always clearly use the word “bullied,” their narratives indicated contexts and indicators consistent with the perception of being bullied. The substantiation of being bullied was indicated in the following seven major themes: compromised learning capacity, loss of sense of agency and decision-making, asexuality, less attractive appearance, less social skills, gender discrimination, and less financial resources. All names are pseudonyms. In addition, the information shared by each participant may contribute to different topics.

Discussion

Outcomes indicate that participants draw upon the following seven nonmutually exclusive themes related to older adult perspectives on bullying in old age: compromised learning capacity, loss of sense of agency and decision-making, asexuality, less attractive appearance, less social skills, gender discrimination, and less financial resources.

The data analysis intended to fill a knowledge gap about older adult perceptions of being bullied and to elaborate an interpretative framework for the bullying construct. Results illustrate that older adults perceived this construct in diverse and rich manners.

Compromised learning capacity was the most frequent theme indicated by these participants. In old age, cognitive function may be slower or impaired, inducing lower learning and information apprehension skills, posing a risk for bullying, violence, or abuse (Faustino et al., 2016; McCausland et al., 2016). Some studies indicate that when older people are less able to learn, they are more vulnerable to abuse, which can configure bullying situations, particularly sexual violence and neglect (Faustino et al., 2016).

Similarly, older adults with cognitive impairment are more likely to be abused by caregivers and family members (M. Lee, 2009). Indeed, one of the main risk factors for abuse in older adults is the occurrence of dementia (McCausland et al., 2016; Sethi et al., 2011). In addition, lower levels of episodic memory, perceptual speed and overall cognition also appear to be associated with an increased risk of abuse (X. Dong et al., 2011). One of the main risk factors for elder abuse is difficulties in assimilating, processing and transforming information; and decreased abilities, such as attention, perception, and language processing, which make them more vulnerable (J. Y. Lee, 2015; Pauwels et al., 2018). Similarly, lower levels of cognitive function appear to be associated with a higher likelihood of being a victim of fraud (James et al., 2014). Annually millions of older people are estimated to be victims of fraud and sometimes in a repeated way, which can configure bullying situations. Some authors attribute this high incidence to declines in cognitive functioning, particularly failure of decision-making processes, which are essential for recognizing, preventing and responding to this type of abuse (Han et al., 2016; James et al., 2014; Shao et al., 2019). Complex and higher order cognitive functions can significantly decrease in older adults, so level of cognitive difficulty also seems to be directly related to prevalence and factors involved in older adult abuse by family members and caregivers (Kishimoto et al., 2013; Pauwels et al., 2018). Also, caregiver sex (male), emotional burden and the nature of the neuropsychiatric symptoms of older adults seem to influence the indicators of psychological and physical maltreatment, but variables such as the older adult’s gender did not show a significant effect on indicators of maltreatment (Kishimoto et al., 2013).

The loss of sense of agency and decision-making was the second most indicated theme related to perception of being bullied. According to Goll et al. (2015), among the greatest fears of older adults are feelings of disability, dependence, uselessness and loss of social roles they once had, which are often accentuated in situations of bullying and discrimination. Loss of sense of agency, together with situations of infantilization (e.g., care homes) and underestimation of their real abilities can configure situations of abuse, which undermine their decision-making and have a direct impact on older adult well-being (Marson & Powell, 2014). Likewise, increasing prejudice and bullying often occurs with loss of sense of agency and decision-making among older adults, in a stereotypical and inappropriate way through withdrawal of functions (e.g., financial decisions, driving), thus significantly affecting their self-concept and self-esteem (Goll et al., 2015). Some authors point out that to prevent bullying, which can lead to discrimination, individual-centered empowerment strategies may be adopted that take into account the goals, aspirations, and desires of older people (Goll et al., 2015; McWilliam et al., 1994).

Being perceived as asexual was a relevant source of bullying for older adults. The stereotype of the older adult as asexual is associated with the prevalence (until the 1960s) of the “reproductive” model of sexuality, in which nonreproductive sexuality, as in old age, is marginalized (Træen et al., 2016). Likewise, discrimination and bullying may also be associated with youth-oriented conceptions of sexuality, where sex is seen as a younger adult privilege (Hurd, 2000; Træen et al., 2016).

Furthermore, stereotyped comments and offenses are a frequent type of bullying, with a significant negative effect on the lives of older adults, when these do not possess sufficient levels of resilience to manage aggressive bullying situations (R. P. Bonifas, 2015; Walsh et al., 2011). In addition, sexual minorities among older adults are further affected by stigmatization due to their sexual orientation (R. P. Bonifas, 2015). Similarly, the higher prevalence of chronic illness and other health problems impacting the sexual function of older people may falsely reinforce the social stereotypes of “asexuality” (Heidari, 2016; Træen et al., 2016). However, there are older adult groups who consider themselves to be effectively asexual and who seem to evidence marked risk factors for erectile dysfunction (e.g., diabetes, hypertension). They also indicate that among the reasons for “asexual” status are stress—probably associated with phenomena of discrimination, stigmatization or abuse—and severe fatigue, such as erectile difficulty, nonconcern about sexuality and masturbation (Huang et al., 2014).

Aging is accompanied by changes in body weight and shape that can negatively influence older people’s self-perception and make them more vulnerable to various forms of abuse and bullying (Træen et al., 2016). Weight stigmatization is common in several studies including older adults and seems to be associated with depressive symptomology, general psychiatric symptoms and decreased self-esteem (Træen et al., 2016). Studies show that stigmatization and bullying in particular have a significant impact, because the causes of body changes are often attributed to the individual’s self-control (Jeffries et al., 2018; NCAL, 2017). In particular, women report a fear of getting old, associated with the social consequences of losing their youthful body, which may be a source of discrimination and bullying (Hurd, 2000; NCAL, 2017).

Bullying can be felt through decreased social skills. Some studies indicate that older people with low social fulfillment have a significant tendency to connect with others, including strangers, making occurrences of abuse and bullying easier (Lichtenberg et al., 2013, 2016). Older people with psychological vulnerability—defined by the authors as a combination of depressive symptoms and poor fulfillment of social needs—were 3 times more likely to be victims of fraud (Lichtenberg et al., 2013; Shao et al., 2019). On the contrary, these difficulties with social context can sometimes manifest themselves in social isolation, increasing the likelihood of abuse due to greater exposure to being misled by others, feelings of loneliness and a weaker support network (X. Q. Dong, 2015; Shao et al., 2019). However, if the older adult caregiver lives in the same house, the risk of abuse is also increased, associated with the high probability of relational problems and emotional overload (Wolf et al., 2002). Moreover, worldwide, social support has been found to significantly reduce the risk of abuse (Pillemer et al., 2016).

Gender discrimination was felt by these older adults in both genders, however 64% of the participants who pointed out this theme were women. Much of the literature suggests that women tend to be more bullied than men (Gil et al., 2015; Jeon et al., 2019), particularly financial and emotional bullying (Pillemer et al., 2016). A recent meta-analysis confirms this trend in Asian, Mediterranean, and European countries, although not in the American continent, where men seem to be the most abused (Yon et al., 2017).

Similarly, sexual minorities are victims of bullying (R. P. Bonifas, 2015). Although little is known about the percentage of LGBT seniors who are bullied, data on the victimization of this population are high. When asked, 82% of LGBT seniors report having suffered bullying behavior (e.g., physical or verbal attack and threat, property damage) at least once and 64% report various bullying behaviors (R. P. Bonifas, 2015).

Finally, participants highlighted being bullied because of lower financial resources. Several studies associate low socioeconomic status with situations of abuse, discrimination and bullying (Naughton et al., 2010; NCAL, 2017; Peterson et al., 2014). Economically more vulnerable groups tend to be more abused during old age and throughout their lives (Peterson et al., 2014). Moreover, bullying and maltreatment can be important tools for theft, fraud, and misuse of power (Rabiner et al., 2004). Particularly, when the perpetrator of abuse is a family member, older people tend not to report the situation, in addition to more passively accepting financial abuse (Kalayci et al., 2016). Specifically, in the domestic context, the prevalence of financial abuse appears to be higher than in institutional contexts, and perpetrators of abuse tend to be mostly family members rather than other caregivers (Hafemeister, 2003; Lachs & Pillemer, 1995, 2015). In several Asian countries, lower monthly household income may contribute to a threefold increase in likelihood of older adult bullying and abuse. These results are similar to those found in other continents (Lachs et al., 1997; Yan et al., 2014).

The present study has a number of limitations. Although this study is cross-national, we only included participants from developed countries. The sample is also not representative of the entire population and only reveals the perceptions of these participants. Sampling was performed purposefully, with the objective of facilitating the understanding of bullying in old age. Furthermore, interviews were conducted sought to be bias free, hence one core area to be addressed was predefined. Because interviews tended to be steered to this area, results could have been biased.

Notwithstanding these limitations, a major strength of this study is that all participants were community-dwelling. Many studies on bullying in older adults are related to so-called “resident-to-resident bullying,” and neglect the study of this type of aggression in community-dwelling older adults (Ferrah et al., 2015; Ferreira et al., 2018). Similarly, most studies obtained their results based on reports from the teams working with older adults and some biases associated with these informants have been underlined (Ferreira et al., 2018).

Another strength is that, considering that bullying is a sensitive theme for research participation, our participants shared their experiences about this subject, Moreover, physical and cognitive limitations resulting from aging tend to decrease the nonresponse rates in the studies, which may lead to underestimate the actual occurrence of aggression (De Donder et al., 2011; Lensvelt-Mulders, 2008). Still, some studies indicate the stigma of bullying among older adults as a major limitation. Hence, research should address these acts of aggression in a comprehensive and integrative manner, understanding that bullying can be the product of older adults expressing frustration regarding unmet needs (Ferrah et al., 2015; Lachs & Pillemer, 2015).

In this study, there was an evident cultural diversity. Portuguese older adults were mostly bullied for their loss of sense of agency and decision-making, less attractive appearance, fewer social skills and financial resources, while English participants felt bullied mostly for their compromised learning capacity, gender discrimination and asexuality. In-depth cross-cultural studies are essential to form the basis for further measures (De Donder et al., 2011). Similarly, studies are fundamental to identify and distinguish bullying behaviors, as well as to establish guidelines for managing such situations (Krug et al., 2002; Mathers et al., 2015). With the accentuated and progressive aging of the population, in the near future research may be an important resource for families, health professionals and older adults themselves in managing situations of aggression (R. P. Bonifas, 2015; Krug et al., 2002; WHO, 2015). Likewise, there are variables that significantly influence the daily lives of older community-dwellers, such as loneliness, social isolation and weak social networks, which favor the emergence of bullying (Krug et al., 2002; McDonald et al., 2015). Because these variables are directly associated with bullying, further studies can allow these variables to be better assessed and addressed (McDonald et al., 2015).

Similarly, future studies on the prevalence of bullying among older adults would be a significant contribution, as there is a scarcity of data (NCAL, 2017). In addition, studies on bullying among older adults will enable the establishment of health policies that improve the prevention of this type of aggression (NCAL, 2017; Pillemer et al., 2016), and may also inform the legislation for better and more appropriate action measures in cases of bullying (Pillemer et al., 2016). Regarding these policies, there is a scarcity of guidelines that address bullying prevention or intervention among older adults (Walsh et al., 2011; Zsoldos et al., 2014). The theoretical inconsistency and the bias toward assessing bullying almost exclusively in the school context, and in childhood, emphasize the need for practical actions in older adulthood (R. P. Bonifas, 2015). However, some evidences (e.g., R. Bonifas & Frankel, 2012; Gutman, 2012a), and the NCAL (2017), have suggested some guidelines for preventing and addressing situations of bullying among older adults, which include committing organizations that care for older adults to comply with the principles of respect and equality; assessing risks and severity of bullying; implementing policies of zero tolerance for bullying; implementing discussions about bullying with the community, professionals, and families; creating community partnerships; developing inclusive informational materials targeted at potential victims and perpetrators; implementing strategies to support and empower victims to better manage bullying situations (e.g., assertiveness training); implementing strategies that support and enable aggressors to manage their control needs in a more adaptive way (e.g., self-control training). In addition, and based on the evidence found in this article, we suggest adding communication strategies for older adults when bullied, developing specific training programs for health professionals; developing strategies for early and comprehensive awareness of bullying in old age; and creating anonymous and confidential helplines aimed at aggressors and elderly victims of bullying.

In brief, in-depth future research is fundamental for the design of psychosocial intervention programs in the management of the above bullying situations in old age, particularly in community-dwelling older adults (Jeon et al., 2019; Powell, 2010).