SYDNEY (AP) — By the time the ambulance showed up to the house, the old woman's screams were, as the paramedics would later tell it, already at a 10 out of 10.
On a bed in the foyer lay 88-year-old Cynthia Thoresen, her eyes screwed up in agony, her skin covered in feces, with a broken leg gone untended for weeks.
The fact that Cynthia even lived in the house was a surprise to the neighbors. None had seen her. None had any idea she'd spent her final days in hellish pain after a fall. None knew that her daughter and caretaker, Marguerite Thoresen, had waited at least three weeks, and up to three months, before calling for help.
In the end, Cynthia Thoresen joined a large and growing cohort of elderly people across the world who live, and increasingly die, in silence, left to fend for themselves against a problem society has barely begun to notice: Elder abuse.
This type of abuse, which often includes neglect, is still so hidden that it is hard to quantify. But the broad picture gleaned from hundreds of interviews and dozens of studies reviewed by The Associated Press is clear: Tens of millions of elders have become victims, trapped between governments and families, neither of which have figured out how to protect or provide for them.
EDITOR'S NOTE — As the world ages faster than ever, who will care for the old? This story is part of an occasional series about elder neglect and abuse worldwide.
Most of the elderly live with family or at home, and researchers estimate at least 4 to 10 percent of them, and probably a lot more, are abused. Even by the lowest count, that means 30 million people.
The demographics alone show the problem is growing. By the year 2050, there will be more old people than children for the first time in history.
Australia, where Cynthia Thoresen lived, is a wealthy nation and considered progressive, but even in high-income countries, the abuse rate is 4 to 6 percent, according to the World Health Organization. And even here, the system repeatedly failed Cynthia, in life and in death.
"Nothing in the past has disturbed me like this job disturbed me," paramedic Christopher Curtis told police. "I've not seen anyone, regardless of their age, that could withstand the level of pain inflicted by a fractured femur for five seconds, let alone three weeks."
In a way, aging in today's world can be a slow slide into invisibility: Older people often say they exist in the shadows, their words dismissed, their cares unheeded.
Information on elder abuse lags decades behind research on child abuse. Only a handful of countries legally require the reporting of suspected elder abuse, compared to dozens for child abuse. In the U.S., the government passed the Elder Justice Act in 2010, compared to 1974 for its counterpart on child abuse.
The data varies wildly across cultures because researchers can't agree on who is an elder, let alone what elder abuse is. But other statistics are telling: Only one in five older people worldwide has a pension. Elders figure prominently among the more than 100 million who fall into poverty each year because of health-care expenses. And the suicide rate among men over 75 is the highest in the world.
Cynthia Thoresen's story can be pieced together through legal documents, newspaper clippings, interviews and police testimony. Marguerite Thoresen did not answer repeated requests, by phone, email and letter, for comment.
Cynthia's world began to shrink with a fall that left her dependent.
She moved into Marguerite's home in Perth, and in 2001, Marguerite applied for a government carer's benefit that came to around $500 every two weeks. Once the payments started, the government welfare agency, Centrelink, never asked for further medical updates on Cynthia, Marguerite said.
Cynthia vanished from the health care system. Medicare records show that for years she saw doctors and took prescription medications. But in 2003, Cynthia's medical treatment stopped.
Marguerite's explanation: "Well, she didn't say she was ill."
In 2007, Marguerite moved with her husband, daughter, grandsons and mother to a Brisbane suburb.
There, Cynthia's world shrank to a pinpoint.
In the 18 months Cynthia lived there, no visitors were invited inside. Cynthia did not talk on the phone or write letters. Her only other close relative, her son Thorolf, lived nearly 1,700 kilometers (1,000 miles) away, and dementia left her confused at times.
One morning, probably in late November 2008, the family found Cynthia on the floor next to a pool of liquid.
Marguerite figured she'd sprained her knee and kept her in bed, with a towel underneath to soak up excrement. She said she called an ambulance on Dec. 17, 2008 because her mother had stopped eating.
She said the screaming only began when she moved Cynthia to a bed near the front door.
Up until this point, she said, her mother seemed fine.
When Cynthia arrived at the hospital, her chafed skin was covered in bedsores and feces. Her toenails were overgrown and curling. Her swollen right leg was 10 centimeters (4 inches) shorter than her left, the result of a fracture healing improperly.
Marguerite didn't ride to the hospital with her mother. She did not show up for three days.
The break appeared to be between three and 12 weeks old. The fracture was too severe and the delay in treatment too long to operate.
Cynthia died at 6:15 p.m. on Jan. 3, 2009. She was one week shy of her 89th birthday.
The coroner would not hold the inquest hearing into her death until four years later.
In Australia, as in many places, experts say the legal system is not set up to prevent, catch or punish elder abuse.
The few regions with mandatory elder abuse reporting laws — including most U.S. states, some Canadian provinces and Israel — still catch only a tiny fraction of cases. And even then, the victims seldom see justice.
Only one case out of the hundreds Diane Pendergast investigated as Queensland's Adult Guardian was prosecuted.
"People won't prosecute — whether it's police, whether it's family members — because it involves family business," she says. "Because it's private. Because there's a level of abuse that's tolerated in the community that none of us wishes was there. We all turn a blind eye."
The autopsy concluded Cynthia died from a blood clot in her lung, sparked by the leg fracture. Dr. Stephen Morrison, the medical expert, concluded Cynthia's condition and the delay in treatment was "neglectful to the point of cruelty in a distressed, demented and totally dependent patient."
Police contemplated charges of manslaughter, failure to provide the necessities of life, negligent acts causing harm, torture. But they decided the doctors couldn't say beyond a reasonable doubt that Marguerite's care had caused Cynthia's death.
So they closed the case.
The key to Cynthia's story lies with her daughter, Marguerite.
The few people who know her describe her as introverted, odd but compassionate. She took in unwanted rabbits and ran an information service dedicated to their care. In a poem on the website, Marguerite writes:
"Miserable howling pierces the night as the pet shop puppy cries a lament that nobody hears ... The solitary victim left to cry alone."
At the inquest on May 13, 2013, the coroner, Christine Clements, and the lawyer, Emily Cooper, grilled Marguerite for two hours. Through it all, she seemed detached.
The excrement? There wasn't that much. Cynthia's screams? They weren't that loud. The stench of urine? The result of her grandson running around without a diaper.
She hadn't accompanied her mother in the ambulance because she didn't think it was allowed. She hadn't visited for three days because her husband was too busy to join her.
Marguerite finally conceded that perhaps she should have called an ambulance a week earlier. But no sooner.
Cooper asked point-blank: Had Marguerite provided Cynthia appropriate care?
"I believe that up to that last fall, she had very good care," Marguerite replied. "I did my best."
And after the fall?
"I probably could have judged the situation better."
In the coroner's 15-page report, the word "pain" appears 30 times.
"It is an appalling thought to consider the pain endured by Cynthia Thoresen during this period when she was totally at the mercy of her daughter's inadequate regime of 'care'," Clements wrote.
Marguerite's brother and sister-in-law declined interviews. Police refused to talk. Centrelink referred AP to the family and housing department, which refused to address possible changes in policy. The state attorney general referred the case to the public prosecutor's office, which also refused to comment.
From all involved: Silence.
"With elder abuse, no one wants to touch it. Any nugget of information that might lead to revelations of abuse is always swept under the carpet," says Lynda Saltarelli, founder of Aged Care Crisis, an Australian advocacy group. "As a community, we should all hang our heads in shame over the fact that it's remained hidden."
In the end, the lawyer concluded there was no evidence of malice from Marguerite, but her explanations were "quite ridiculous."
The coroner mused aloud about the troubling death of such a dependent, vulnerable elderly person, and asked, "How as a society can we help such an event occurring?"
Did it come down to changing the law? Was it about moral, family, social responsibility? Did Marguerite herself need help?
The coroner let out a small sigh. Her voice was resigned.
"I don't know."
Her words were met with silence. Marguerite had left the room.
An interactive is available at http://hosted.ap.org/interactives/2013/global-aging/index.html.
A portrait gallery is at http://hosted.ap.org/interactives/2013/old-world-portraits/index.html.