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

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?

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)

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

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

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

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

Psychological signs of abuse in an older person appears depressed, frightened, withdrawn, apathetic, anxious or aggressive makes great efforts to please appears afraid of being, or unwilling to be treated by a specific member of staff appears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

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

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

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

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

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’

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

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

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

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

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.

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

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

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’

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

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

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

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

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’

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?

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

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

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