Violence against the elderly: a retrospective analysis from a forensic medicine perspective

Abstract

BACKGROUND

In many contemporary studies, individuals aged 65 years and older are defined as older adults. Owing to population aging, the number of older adults worldwide is steadily increasing. Age-related physical and cognitive decline, together with social changes, may increase vulnerability to violence in this population. This study aimed to present and discuss data on older adults aged 65 years and over who were victims of violence and underwent medicolegal evaluation, to draw attention to measures that may help prevent violence against older adults, and to propose potential strategies for prevention and intervention.

METHODS

A total of 275 case files and forensic reports pertaining to individuals aged 65 years and older who underwent medicolegal assessment at the Department of Forensic Medicine, Dokuz Eylul University Faculty of Medicine, between January 1, 2016 and January 1, 2025, were retrospectively reviewed. Sociodemographic characteristics, location of the violent incident, perpetrator characteristics, type of violence, injury site, wound type, presence of a psychiatric diagnosis related to the incident, type of psychiatric diagnosis, and the forensic medical severity of injuries were evaluated. Statistical analyses were performed using IBM SPSS version 29.0.

RESULTS

Among the 275 cases of violence, 97 (35.3%) involved women and 178 (64.7%) involved men. The mean age was 71.53±6.2 years. The most common perpetrators were unknown or unrelated individuals (n=105, 38.2%), followed by friends or neighbors (n=90, 32.7%). Violence most frequently occurred in the home or its immediate surroundings (n=143, 52%), followed by streets, parks, and other public outdoor areas (n=69, 25.1%). Domestic violence accounted for 21.5% of cases. Neglect was identified in 19 cases (6.9%). Isolated physical violence was the most common form of violence (n=238, 86.5%). The injuries were life-threatening in 21 cases (7.6%), while bone fractures were documented in 78 cases (28.4%).

CONCLUSION

Specific legal regulations should be implemented to better protect older adults and support their participation in social life. Additionally, comprehensive strategies should be developed to address violence against older adults both within and outside the family setting. A multilevel, integrated approach is needed to improve prevention and intervention efforts through the identification of individuals at risk of perpetrating or experiencing violence.

INTRODUCTION

In many developed countries, individuals aged 65 years and older are generally classified as older adults. Old age is commonly divided into three stages: early old age (65–74 years), middle old age (75–84 years), and advanced old age (≥85 years).^[1-3]

Declining fertility rates and increasing life expectancy have led to a rapid rise in the global older adult population. The worldwide population aged 65 years and older was estimated to increase from approximately 550 million in 2000 to 973 million by 2030. Similarly, the number of individuals aged 80 years and older, estimated at approximately 9.3 million in 2000, is expected to reach 19.5 million by 2030. According to United Nations projections, the proportion of older adults in the global population is expected to increase from 10% to 17% between 2021 and 2050.^[3,4] According to data from the Turkish Statistical Institute (TURKSTAT), the number of older adults in Türkiye reached 8,722,806 in 2023, and the proportion of individuals aged 65 years and older increased from 7.1% in 2007 to 10.6% in 2024. Population projections indicate that this proportion will rise to 13.5% in 2030, 17.9% in 2040, 27% in 2060, 33.4% in 2080, and 33.6% in 2100.^[5,6]

Aging is associated with various physiological and functional changes, including slower cognitive processing, impaired attention and perception, declines in sensory functions such as hearing and vision, reduced muscle strength, and delayed reflex responses. In addition to these age-related changes, socioeconomic challenges and social transformations may increase vulnerability to violence among older adults. Insufficient social support further exacerbates this vulnerability and may contribute to the occurrence of violence against older individuals.^[7-16]

Available evidence indicates that violence against older adults is increasing both globally and in Türkiye.^[14-17] Consequently, violence against older adults remains an important public health concern. Therefore, the dissemination of current data on this issue may contribute to raising awareness and informing the development of evidence-based strategies and interventions aimed at its prevention and management.

This study aimed to present and discuss data on individuals aged 65 years and older who were victims of violence and underwent forensic evaluation, to highlight measures that may help prevent violence against older adults, and to propose potential solutions for addressing this problem.

MATERIALS AND METHODS

This study examined the sociodemographic characteristics of individuals aged 65 years and older who were victims of violence and underwent medicolegal evaluation at the Department of Forensic Medicine, Dokuz Eylul University Faculty of Medicine. The variables evaluated included the location where the violent incident occurred, perpetrator characteristics, type of violence, injury site, wound type, presence of a psychiatric diagnosis related to the incident, psychiatric diagnoses established, and the forensic medical severity of the injuries. For this purpose, a total of 275 case files and forensic reports belonging to individuals aged 65 years and older who were subjected to violence and underwent medicolegal assessment between January 1, 2016 and January 1, 2025, were retrospectively reviewed. This study was approved by the Dokuz Eylul University Faculty of Medicine Ethics Committee (Date: 12.03.2025, Decision No: 2025/09-18) and was conducted in accordance with the principles of the Declaration of Helsinki.

Statistical Analysis

Statistical analyses were performed using IBM SPSS version 29.0 (IBM; International Business Machines, New York, USA). Continuous variables were summarized as mean ± standard deviation, whereas categorical variables were expressed as percentages. Associations between categorical variables were analyzed using Pearson's chi-square test or the Fisher–Freeman–Halton exact test. A p value <0.05 was considered statistically significant.

RESULTS

Among the 275 cases of violence included in the study, 97 (35.3%) involved women and 178 (64.7%) involved men. The mean age of the victims was 71.53±6.2 years (range, 65–90). According to age-group analysis, 202 cases (73.5%) were aged 65–74 years, 61 (22.2%) were aged 75–84 years, and 12 (4.4%) were aged 85 years and older (Fig. 1).

Figure 1.

Distribution of cases according to age group.

The most common perpetrators of violence were unknown or unrelated individuals (n=105, 38.2%), followed by friends or neighbors (n=90, 32.7%) (Table 1). Among all perpetrators, 232 (84.4%) were male and 43 (15.6%) were female. Violence was perpetrated by a single individual in 240 cases (87.3%) and by multiple individuals in 35 cases (12.7%).

Table 1.

Distribution of perpetrators of violence according to location of the incident

Perpetrator	Home and surroundings	Nursing home	Traffic	Open area	Workplace and surroundings	Other	Total
Spouse	17 (11.9%)	-	-	1 (1.4%)	-	-	18 (6.5%)
Child	29 (20.3%)	-	-	-	-	-	29 (10.5%)
Other relative	21 (14.7%)	-	-	3 (4.3%)	-	1 (9.1%)	25 (9.1%)
Friend/neighbor	59 (41.3%)	5 (41.7%)	1 (4.5%)	13 (18.8%)	8 (44.4%)	4 (36.4%)	90 (32.7%)
Caregiver	1 (0.7%)	6 (50%)	-	-	-	-	7 (2.5%)
Unknown/unrelated
person	16 (11.2%)	1 (8.3%)	21 (95.5%)	51 (73.9%)	10 (55.6%)	6 (54.5%)	105 (38.2%)
Other	-	-	-	1 (1.4%)	-	-	1 (0.4%)
Total	143 (100%)	12 (100%)	22 (100%)	69 (100%)	18 (100%)	11 (100%)	275 (100%)

^*Percentages are calculated within each column.

The most common location where violence occurred was the home and its immediate surroundings (n=143, 52%), followed by streets, parks, and other open public areas (n=69, 25.1%). In addition, 22 cases (8%) occurred in traffic-related settings, whereas 12 cases (4.4%) occurred in nursing homes. Among incidents occurring in the home and surrounding environment, the perpetrator was most frequently a friend or neighbor (n=59, 41.3%), followed by a child (n=29, 20.3%), another relative (n=21, 14.7%), and a spouse (n=17, 11.9%). Nearly half of the incidents involving unknown or unrelated perpetrators (n = 51, 48.6%) occurred in open public areas, whereas 21 cases (20%) occurred in traffic-related settings (Table 1).

Domestic violence was identified in 59 cases (21.5%), whereas 216 cases (78.5%) did not involve domestic violence. Elder neglect was not identified in the majority of cases (n=256, 93.1%). Neglect was documented in only 19 cases (6.9%).

The most common form of violence was isolated physical violence (n=238, 86.5%), followed by combined physical and psychological violence (n=19, 6.9%). Among the three cases involving sexual violence, one involved anal penetration and two involved unwanted touching. With regard to the mechanism of injury, blunt-force trauma was the most common cause (n=251, 91.3%), followed by injuries caused by sharp or penetrating objects (n=15, 5.5%), and firearm-related injuries (n=9, 3.3%).

Among cases of domestic violence, isolated physical violence was the most common form (n=28, 47.5%), followed by combined physical and psychological violence (n=15, 25.4%), and combined physical, economic, and psychological violence (n=10, 16.9%) (Table 2).

Table 2.

Distribution of domestic violence according to type of violence

Domestic violence status	Physical	Physical/sexual	Physical/psychological	Physical/economic	Physical/economic/psychological	Total
Absent	210 (97.2%)	2 (0.9%)	4 (1.9%)	-	-	216 (100%)
Present	28 (47.5%)	1 (1.7%)	15 (25.4%)	5 (8.5%)	10 (16.9%)	59 (100%)
Total	238 (100%)	3 (100%)	19 (100%)	5 (100%)	10 (100%)	275 (100%)

^*Percentages are calculated within each row.

Most victims were injured by kicks, punches, or similar forms of physical assault (n = 204, 74.2%), whereas 24 cases (8.7%) involved objects such as sticks or iron rods. Injuries most commonly involved the head, neck, and face region (n=114, 41.5%), followed by injuries affecting multiple body regions (n=70, 25.5%). Upper-extremity injuries were observed in 52 cases (18.9%). Regarding wound characteristics, ecchymosis and edema were the most common findings (n=118, 42.9%), followed by multiple wound types (n=82, 29.8%). Bone fractures were not identified in the majority of cases (n=197, 71.6%). No medical treatment was required in 115 cases (41.8%), whereas wound care or other medical treatment was provided in 75 cases (27.3%). A summary of the characteristics of elder abuse cases is presented in Table 3.

Table 3.

Summary of violence-related characteristics among older adult victims

Instrument used in the assault

Blunt object (stick, iron bar, etc.) (n=24, 8.7%)

Sharp object (knife, glass, etc.) (n=17, 6.2%)

Firearm (n=9, 3.3%)

Other (n=21, 7.6%)

No instrument used (n=204, 74.2%)

Injury site

Head, neck, and face (n=114, 41.5%)

Abdomen, chest, and back (n=29, 10.5%)

Upper extremity (n=52, 18.9%)

Lower extremity (n=10, 3.6%)

Multiple body regions (n=70, 25.5%)

Wound type

Ecchymosis/edema (n=118, 42.9%)

Abrasion (n=33, 12%)

Laceration/incision (n=23, 8.4%)

Sharp penetrating injury (n=8, 2.9%)

Gunshot wound (n=7, 2.5%)

Multiple wound types (n=82, 29.8%)

Other (n=4, 1.5%)

Bone fracture

Present (n=78, 28.4%)

Absent (n=197, 71.6%)

Treatment administered

Medical treatment/wound dressing (n=75, 27.3%)

Minimal intervention (n=47, 17.1%)

Surgical treatment (n=27, 9.8%)

Other (n=11, 4%)

No treatment required (n=115, 41.8%)

Psychiatric evaluation following exposure to violence was not performed in most cases (n=247, 89.8%). Among the 28 cases that underwent psychiatric assessment, 20 (7.3%) received a psychiatric diagnosis and eight (2.9%) did not. The most common psychiatric diagnoses were post-traumatic stress disorder (n=9, 45%), adjustment disorder (n=7, 35%), and acute stress disorder (n=4, 20%) (Table 4).

Table 4.

Psychiatric and forensic medical findings among older adult victims of violence

Psychiatric evaluation

Psychiatric diagnosis established (n=20, 7.3%)

No psychiatric diagnosis established (n=8, 2.9%)

Not evaluated (n=247, 89.8%)

Psychiatric diagnosis

Post-traumatic stress disorder (n=9, 45%)

Adjustment disorder (n=7, 35%)

Acute stress disorder (n=4, 20%)

Forensic medical assessment

Injury manageable with simple medical intervention (n=151, 54.9%)

Injury not manageable with simple medical intervention (n=124, 45.1%)

Life-threatening condition

Present (n=21, 7.6%)

Absent (n=254, 92.4%)

Among the 20 individuals diagnosed with a psychiatric disorder following violence exposure, 10 (50.0%) were male and 10 (50.0%) were female. No statistically significant association was found between victim sex and the presence of a psychiatric diagnosis following exposure to violence (p=0.227).

From a forensic medical perspective, injuries in 151 cases (54.9%) were considered manageable with simple medical intervention, whereas injuries in 124 cases (45.1%) were considered not manageable with simple medical intervention. The injuries were life-threatening in 21 cases (7.6%) and non-life-threatening in 254 cases (92.4%) (Table 4).

Among the 232 cases involving male perpetrators, 115 (49.6%) resulted in injuries that were not manageable with simple medical intervention. In contrast, among the 43 cases involving female perpetrators, 34 (79.1%) resulted in injuries that were manageable with simple medical intervention. A statistically significant association was identified between perpetrator sex and injury severity as assessed by the need for simple medical intervention (p<0.05).

DISCUSSION

Preventing violence against older adults is essential not only for protecting individual health and well-being but also for promoting a healthy social structure. Available data indicate that violence against older adults is increasing in parallel with the growing proportion of the older adult population. Although growing awareness of the issue has led to an increase in the number of studies conducted in this field, the available literature remains limited. Therefore, the dissemination and discussion of data from different institutions and regions are crucial for raising awareness and developing effective prevention and intervention strategies.

In the present study, men constituted the majority of victims of violence (n=178, 64.7%). In this regard, our findings are consistent with previous studies reporting that exposure to violence is more common among men.^[1,18,19] This pattern may be explained by men's greater participation in occupational and social activities, as well as gender-related behavioral differences. However, some studies have reported that women are more frequently victims of violence in older age groups.^[20-22]

Most victims in our study were aged 65–74 years (n=202, 73.5%), corresponding to the early stage of old age. This finding is consistent with previous studies demonstrating that violence is more frequently reported among individuals in the younger segment of the older adult population.^[18,23,24]

Violence against older adults may be perpetrated by both strangers and individuals known to the victim. Previous studies have indicated that approximately half of all victims experience abuse perpetrated by family members or acquaintances.^[25,26] Santos et al.^[24] reported that spouses or partners were the most common perpetrators, followed by children and grandchildren. Similarly, Paiva and Tavares found that partners (29.1%) and caregivers (25%) were the most common perpetrators of violence against older adults.^[27] In contrast, the most common perpetrators in our study were unknown or unrelated individuals (38.2%), followed by friends and neighbors (32.7%).

Regarding perpetrator sex, 84.4% were male and 15.6% were female. This finding is in agreement with previous studies reporting similar results.^[21,22,28]

Violence against older adults may occur in a variety of settings, including nursing homes, and assisted living facilities; however, previous studies have reported that most incidents occur in the home environment.^[29] Consistent with these findings, the most common location of violence in our study was the home and its immediate surroundings (n=143, 52%), followed by streets, parks, and other public outdoor areas (n=69, 25.1%). Sivarajasingam et al.^[30] reported that most older adults presenting to emergency departments after violent incidents had been assaulted in their homes.Likewise, a report from the Canadian Centre for Justice and Public Safety Statistics indicated that 71% of older adults who experienced violence were victimized in residential settings, including private residences (83%) and shared accommodations such as nursing homes or care facilities (15%).^[31]

The same report noted that violence occurring in shared residential settings was most frequently perpetrated by acquaintances (40%), neighbors (19%), strangers (11%), roommates (9%), or authority figures (7%).^[31] In the present study, friends or neighbors were the most common perpetrators of violence occurring in the home environment (41.3%), followed by children (20.3%). Nearly half of the incidents involving unknown or unrelated perpetrators occurred in public outdoor areas (48.6%), whereas one-fifth occurred in traffic-related settings (20%).

Violence against older adults may take many forms, including physical, psychological, sexual, and economic abuse. In addition, neglect refers to the failure to meet an older adult's basic needs, such as adequate nutrition, shelter, personal care, or medical treatment. Previous studies have reported substantial variation in the prevalence and types of violence experienced by older adults.

In a study of 729 cases, Paiva and Tavares reported that psychological violence was the most common form of abuse (20.9%), followed by physical violence.^[27] In a study conducted in the United States involving 5,777 older adults, 11.4% of participants reported experiencing violence, including psychological violence (4.6%) and physical violence (1.6%).^[25] Other studies have similarly reported that psychological violence is the most prevalent form of abuse among older adults, with rates ranging from 11.6% to 33.4%.^[32,33] In contrast, another large-scale study conducted across 524 cities found that 67.7% of older adults who experienced violence were victims of physical violence, whereas 29.1% were victims of psychological violence.^[34] Santos et al.^[24] reported that physical violence was the most common form of abuse among older adults (84.7%), followed by psychological violence manifested as verbal aggression, insults, and humiliation (62%).Likewise, according to the Canadian Centre for Justice and Public Safety Statistics, physical force was used in more than half (60%) of police-reported cases of violence against older adults, and weapons were involved in 19% of these incidents.^[31] Consistent with these findings, isolated physical violence was the most common form of violence observed in our study (86.5%), followed by combined physical and psychological violence (6.9%). Among physical assaults, blunt-force trauma was the predominant injury mechanism (91.3%), followed by injuries caused by sharp or penetrating objects (5.5%) and firearm-related injuries (3.3%).

In our study, 21.5% of cases (n=59) were classified as domestic violence. Among these cases, isolated physical violence was the most common form of abuse (47.5%), followed by combined physical and psychological violence (25.4%). Barros et al.^[35] reported a domestic violence prevalence of 78.7% among 169 older adults receiving primary healthcare services. Duque et al.^[36] and Aleissa et al.^[37] reported corresponding rates of 20.8% and 54.7%, respectively. Frazão et al.^[22] found that isolated physical violence was the most common form of domestic violence among older adults with disabilities (86%). Barros et al.^[35] reported that 21.5% of older adults exposed to domestic violence experienced psychological abuse, whereas 3% experienced physical abuse. Similarly, Apratto Júnior reported prevalence rates of 10% for physical violence and 43.2% for psychological violence among older adults exposed to domestic violence.^[38]

Neglect was identified in 19 cases (6.9%) in our series. prevalence was lower than those reported in previous studies, in which rates of elder neglect ranged from 13.8% to 58.5%.^[35,37,39]

Among the 28 individuals who underwent psychiatric evaluation following exposure to violence, 20 (7.3%) received a psychiatric diagnosis, whereas eight (2.9%) did not. The most common diagnosis was post-traumatic stress disorder (45%), followed by adjustment disorder (35%). Choi et al.^[40] reported that post-traumatic stress disorder was identified in 62.2% of individuals exposed to violence. Similarly, Fadeeva et al.,^[41] in a study examining the relationship between violence against older adults and mental health in the United Kingdom, reported that 26.4% of victims had common mental disorders, including anxiety and depressive disorders.

In our study, psychiatric diagnoses following exposure to violence were equally distributed between men and women, with each sex accounting for 50% of diagnosed cases. No statistically significant association was found between victim sex and the presence of a psychiatric diagnosis following exposure to violence (p=0.227).

De Sousa et al.^[42] reported that, among elderly victims of physical violence evaluated at a forensic medicine unit in Brazil, 56.7% sustained injuries without the use of a weapon or instrument, and 42.9% of injuries involved the jaw and facial region. Similarly, Yıldız reported that 54.5% of older victims sustained injuries without the use of any instrument and that the head and neck region was the most frequently injured anatomical site (55.8%).^[43] Consistent with these findings, our study showed that 74.2% of victims sustained injuries without the use of a weapon, most commonly as a result of kicking or punching, and that the head, neck, and face region was the most frequently affected anatomical site (41.5%).

Karbeyaz and Çelikel reported that 68.4% of injuries among older victims of violence were manageable with simple medical intervention.^[44] de Sousa et al.^[42] found that 90.1% of injuries were limited to soft-tissue damage. Similarly, Yıldız reported that most injuries (71.2%) were manageable with simple medical intervention, whereas 28.8% resulted in serious outcomes such as life-threatening conditions, permanent disability, loss of function, or permanent facial scarring.^[43] In our study, 54.9% of injuries were considered manageable with simple medical intervention, and the vast majority (92.4%) were not life-threatening. Among incidents perpetrated by men, 49.6% resulted in injuries that were not manageable with simple medical intervention, whereas 79.1% of incidents perpetrated by women resulted in injuries that were manageable with simple medical intervention. A statistically significant association was identified between perpetrator sex and injury severity, as assessed by the need for simple medical intervention (p<0.05).

CONCLUSION

This study demonstrated that older adults are most frequently subjected to isolated physical violence perpetrated by unknown or unrelated individuals and by friends or neighbors. These incidents most commonly occur in the home and its immediate surroundings, as well as in public areas such as streets and parks. Although domestic violence accounted for 21.5% of all cases, this proportion remains substantial and should not be overlooked. Furthermore, injuries resulting from violence perpetrated by men were significantly more severe than those resulting from violence perpetrated by women. In light of these findings, legal measures aimed at protecting older adults should be strengthened to promote their safety and active participation in society. In addition, aggravating legal provisions should be considered for offenses involving violence against older adults. Because violence against older adults occurs in diverse forms and contexts, a single, generalized approach is unlikely to address the complexity of the problem. Therefore, tailored strategies should be developed to prevent and combat violence against older adults both within and outside the family setting. A coordinated, multilevel approach is needed to improve prevention and intervention strategies by identifying individuals at risk of either perpetrating or being subjected to violence.

Ethics Committee Approval

This study was approved by the Dokuz Eylul University Faculty of Medicine Ethics Committee (Date: 12.03.2025, Decision No: 2025/09-18).

Informed Consent

Retrospective study

Peer-review

Externally peer-reviewed.

Authorship Contributions

Concept: Ç.S., N.A., M.H.Ö.; Design: Ç.S., M.H.Ö.; Supervision: M.H.Ö., Ç.S.; Resource: N.A., Ç.S.; Materials: Ç.S., N.A., M.H.Ö.; Data collection and/or processing: Ç.S., M.H.Ö., N.A.; Analysis and/or interpretation: Ç.S., M.H.Ö.; Literature review: Ç.S., N.A., M.H.Ö.; Writing: Ç.S., N.A., M.H.Ö.; Critical review: M.H.Ö., Ç.S.

Conflict of Interest

None declared.

Financial Disclosure

The author declared that this study has received no financial support.