1. ELDER ABUSE
‘a single or repeated act or lack of appropriate action occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person’
Action on Elder Abuse

2. Elder Abuse What is its history? What are the types of elder abuse?
What should geriatricians know and do about it?
What is happening about legislation?

3. The history of the syndrome
1975 – ‘granny battering’
1988 – all US states had legislation addressing elder abuse
1988 – UK major BGS conference ‘Abuse of elderly people: an unnecessary and preventable problem’
1990 – Dept of Health commissioned work
1993 – Action on Elder Abuse formed
late 90s/early 00s – Age Concern Scotland work on elder abuse leading to formation of Vulnerable Adults Alliance Scotland (VAAS)

5. Clearing House on Abuse and Neglect of the Elderly (CANE)
University of Delaware hosts this on behalf of NCEA
5000+ holdings
Research / training / government documents / other sources of information

6. How common is it? Is there an ‘iceberg’?
1992 Ogg and Bennett – with Channel 4 and the OPCS: 5% of older people reported some kind of abuse; 2% reported physical abuse. Other UK studies report similar population levels; but possibly up to 50% in vulnerable population
Compare eg Israel 18.4% of older people report being abused;
Hong Kong : 27.5% of elder Chinese reported abuse

7. What types of abuse occur?
Physical
Emotional
Financial
Sexual
Neglect and abandonment

8. Physical signs of abuse in an older person
multiple bruising including bruising on well protected areas, for example inner thigh, or bruising at different stages of healing
finger marks
burns especially in unusual places
an injury similar to a shape or an object
unexplained fractures
inappropriate use of medication, for example, overdosing

9. Psychological signs of abuse in an older person
appears depressed, frightened, withdrawn, apathetic, anxious or aggressive
makes great efforts to please
appears afraid of being, or unwilling to be treated by a specific member of staff
appears afraid of a relative or carer
displays fear or apprehension or distress before or after a visit from a relative, carer or other visitor
displays reluctance to be discharged to his, or her previous circumstances., particlularly if living with another person

10. Financial abuse
unexplained withdrawals from a patient’s savings account
an unexplained shortage of money, despite adequate income
a sudden transfer of assets to a relative
the disappearance of bank statements and valuables including jewellery, clothes, personal possessions and money
inability to explain what is happening to his or her income
reluctance on the part of the family, friends or the person controlling funds to pay for replacement clothes or other necessities

12. Signs of sexual abuse in an older person
pain, itching or injury to the anal, genital or abdominal area; bruising and bleeding of external genitalia
torn, stained or bloody underclothes
venereal disease or recurrent bouts of cystitis
unexplained problems with urinary catheters

13. Signs of neglect in an older person
weight loss
unkempt appearance, dirty clothing and poor hygiene
pressure ulcers or uncharacteristic problems with continence
inadequate nutrition and hydration
inadequate or inappropriate medical treatment or withholding treatment

15. Older peoples’ perception of abuse
Neglect – including isolation, abandonment and social exclusion
Violation of human, legal and medical rights
Deprivation of choices, decisions, status, finances and respect

16. What about healthcare staff?
House of Commons Health Committee 2004
‘a lack of staff awareness of what constitutes abuse – including poor practices – and inadequate knowledge and training in how to detect abuse, can lead to under – reporting of cases’

17. Awareness
Doctors?
study of 250 family physicians and 250 hospital doctors
72% reported no or minimal awareness of elder abuse and more than 50% had never identified a case
Most estimated abuse incidence at around 25% of correct figure
over 60% had never enquired about abuse
most would be reluctant to intervene

18. Nurses?
potentially pivotal role in prevention, detection and resolution
awareness of abuse is not a mandatory part of pre or post-registration nurse education nor mandatory for National Vocational Qualification (NVQ)
study of 718 community nurses suggested 88% encountered elder abuse and 12% of those did so monthly or more frequently

19. Where should awareness be highest?
Accident and emergency departments
Orthopaedic units
Medicine for the elderly
Old age psychiatry
Primary care in vulnerable older people
Some screening instruments available – none ideal for general use

20. General Public? Much more awareness of child abuse
Reluctance to accept – especially sexual abuse
Sometimes financial abuse regarded as relatively benign
Current attempts to raise public awareness and dispel myths - victims need to be aware help is available
Age Concern Scotland piloting an information booklet

21. Key risk factors associated with physical and psychological abuse in the domestic setting
social isolation – those who are abused usually have fewer contacts than those who are not abused
a history of a poor quality long-term relationship between the abused person and the abuser
a pattern of family violence because the abuser may have been abused as a child
the dependence of the abuser on the abused, for example, for accommodation, financial and emotional support.
a history of mental health problems, for example, a personality disorder, or drug or alcohol problems in the person that abuses.

24. Institutional abuse
Much less literature about this – possibly difficulty assessing extent and defining
Considerable source of concern to patients and families
Does not just mean care homes – few hospitals have up to date guidelines on recognising / avoiding abuse

25. Types of institutional abuse
Abusive / assaultive behaviour eg slapping, pulling hair, shaking
Abusive treatments / practices eg restraints, group bathing, public toileting
Abusive attitudes eg belittling comments, neglect of need for privacy, humiliation

26. Is institutional abuse common?
Impossible to say accurately but ‘not uncommon’
One USA study found that 36% of nursing home nurses had witnessed physical abuse; 10% admitted abusing; 81% had witnessed psychological abuse and 40% had committed it – ‘mostly yelling at patients’

27. Predisposing factors in instutional abuse
Facility risk factors
Staff turnover
Caregiver stress
Absent or inadequate prevention policies and awareness training

28. Predisposing factors - continued
Resident risk factors
Behavioural issues (mainly dementia)
Unmet needs
Relationship risk factors
Lack of family involvement
Problems in staff / resident interaction

29. Addressing institutional abuse
Appropriate care home policies and prodedures
Licensing of homes
Inspection eg Care commission
Staff screening

30. Adult Support and Protection Bill
Just gone through Stage 1 in Scottish Parliament
Relates to vulnerable adults not solely older people
Currently too all-encompassing and includes ageing as reason to apply legislation which includes forcible removal from home and over – riding consent
Enable and SAMH have already expressed concerns that not helpful for disabled adults

31. New bill (continued)
Committee report : ‘the term abuse should be removed from the Bill and replaced with a less pejorative term so that it does not stigmatise and alienate those who have only been guilty of benign neglect, resulting in attempts to improve circumstances for the adult being hindered’

32. New bill (continued) Change suggested is to term ‘serious harm’
Age Concern Scotland unhappy with this change - feel the word harm not the
same
What do you think?

33. Principles of managing abuse
Balance of freedom versus safety
Self – determination where adult has capacity
Participation in decision making
Least restrictive option usually best

34. Clinical management of elder abuse
Detection – has abuse occurred?
Assessment – taking into account physical and mental health issues, cognitive and functional status, support systems in place, family issues, nature of abuse
Planning intervention
Follow-up

35. Summary
Elder abuse is a significant issue for older people and anyone involved in their care
Staff must be alert to the possibility of abuse and be able to recognise the problem
If in doubt discuss with a colleague – don’t ignore