About one in 10 elderly people suffer from some form of abuse but they rarely mention it without prompting
About one in 10 elderly people suffer from some form of abuse but they rarely mention it without prompting.
It was bruises on the arm of a frail, elderly patient in a nursing home that alerted Sydney GP Dr Elizabeth Hindmarsh to a problem.
“I saw she had marks at the top of her arm – she’d been held and been bruised. It was obvious she had been restrained in some way,” she recalls.
The patient hadn’t raised the issue. Dr Hindmarsh says in all her years in general practice, no elderly patient has ever disclosed information about being abused without being prompted.
In that instance, she was able to discuss the issue with the patient, her family and the home’s director of nursing, and it was sorted out.
But physical abuse is only one type of abuse to which vulnerable, elderly people are subject, and the signs aren’t always so obvious, says Dr Hindmarsh, co-author of the RACGP White Book on Abuse and Violence.
Abuse can take many forms, with Australian figures showing that elderly people are actually at greatest risk of financial and psychological abuse, followed by physical abuse, neglect, social abuse and sexual abuse (see box at right).
It remains very much a hidden problem, with elderly people fearful of the consequences of speaking out.
But now the issue of elder abuse is gaining traction with governments. Nearly all states and territories have dedicated agencies or helplines to deal with elder abuse, and in NSW, a parliamentary inquiry into the issue is underway.
The SA government recently launched an elder abuse awareness campaign with advertisements appearing on radio, print and social media, bus shelters and doctors’ surgeries, and the Federal Government recently appointed a new independent aged care complaints commissioner to investigate cases relating to residential or home-based aged care services.
HOW BIG IS THE PROBLEM?
The full extent of elder abuse is not clear, but all agree it is under-reported, and is set to grow as the population ages and we live longer.
A recent NEJM review estimated the overall prevalence of elderly abuse to be approximately 10%.
“A busy physician caring for older adults will encounter a victim of such abuse on a frequent basis, regardless of whether the physician recognises the abuse,” the authors wrote.
In NSW, research suggests a prevalence of elder abuse of between 2% and 6% of older people, according to a submission from the Australian Association of Gerontology Council to the current NSW inquiry.
The Council on the Ageing NSW says that based on the conservative estimate of 2%, this means about 20,000 cases in NSW alone.
The Australian Longitudinal Study on Women’s Health, which has been collecting data from three cohorts of Australian women since 1996, includes questions about women’s risk and experiences of abuse.
The study uses a measure that identifies four factors – vulnerability, coercion, dependence and dejection – which have been reported by up to 22% of Australian women aged 70 to 75 years.
Study researcher Dr Meredith Tavener, who co-authored a submission to the current NSW inquiry, says analysis of written comments made by older women gives important information about the types of abuse that women experience – including assault, unwanted sexual activity, bullying, verbal abuse, indirect intimidation, exploitation, financial abuse, theft, lack of privacy, damage to property, not being listened to, ageism and isolation.
“Awareness is increasing, but I still think it can be very easy to miss,” says Dr Tavener, research fellow at the Research Centre for Generational Health and Ageing, at the University of Newcastle.
“It is very invisible and older women can be very stoic and will use different language to describe what is happening.”
|Types of abuse
|• FINANCIAL – such as forced changes to legal documents, misuse of a credit card, denying access to personal funds
• SOCIAL – such as preventing contact with family and friends, living in and taking control of the person’s home or preventing them from engaging in cultural or religious practices
• PHYSICAL – such as slapping, hitting, kicking, physical restraint, over or undermedicating or handling an older person too roughly
• PSYCHOLOGICAL – such as verbal intimidation, humiliation, shouting, threats, withholding affection or removal of decision-making power
• SEXUAL – such as sexual assault or harassment, sexually offensive language and or material, inappropriate touching
• NEGLECT – such as preventing the person from accessing aged care services, receiving a carers’ allowance but not providing care, or failing to provide adequate food, water, clothing, medical treatment etc
Source: Elder Abuse National Annual Report 2013-14, Advocare
For example, rather than talking about being abused, they might mention their partner or carer getting “cross” or “cranky”. Council on the Ageing NSW president Ian Day, who gave evidence to the NSW inquiry late last year, says the community is not generally aware what elder abuse is and how it happens, or of who the major perpetrators are.
“Many people would be shocked to know it’s their kids that are their future abusers,” he says. “Most people think about it in terms of domestic violence, but it ain’t domestic violence. Principally, it’s psychological abuse and financial abuse, and in the main, it’s the kids that are doing it – the sons and daughters.”
About nine out of 10 perpetrators of elder abuse are related to the victim, research shows.
The profile of an elder abuse perpetrator detailed in Advocare’s national report on elder abuse for 2013-14 highlighted that:
- 54.5% of perpetrators are male and 45.5% were female
- 32.2% of perpetrators are the older person’s son, and 30.7% are the older person’s daughter
- Substance abuse, drug addiction and mental health issues are often common factors among perpetrators
A study by Senior Rights Victoria released last year showed that among 455 clients who reported elder abuse, financial abuse was the most commonly reported matter, with women at highest risk. That was followed by psychological and emotional abuse.
In NSW, the Elder Abuse Helpline, which opened in April 2013, had received 3338 calls by August 2015. The number of calls has increased steadily, with 1571 calls received in 2014-15, up 30% on the previous financial year. Among those callers, psychological and financial abuse are again the most commonly reported types of abuse (See box).
Ian Day believes elderly people need to be encouraged to think about issues such as who they would like to look after them and who they would trust as power of attorney well in advance of needing to take those steps.
He says once abuse starts, the abuser tries to isolate the elderly person so they can’t disclose what’s happening.
“The number one enabler for abuse to happen is isolation,” he says.
“When an elderly person stops going to their regular clubs and activities, those around them should keep a watch on their welfare.”
Isolation and a lack of social support are the greatest risks for elder abuse, according to the NEJM review, which says other risks include having a shared living environment and low income.
Older people put their greatest trust in doctors, along with ministers of religion, says Mr Day, putting them in a position to help identify those at risk of abuse.
“They are both in a position to be able to say to the suspected abuser, I want to talk to mum or dad alone. Then have the conversation, slowly, slowly. It’s going to take time.
“GPs and practice nurses, is where it’s going to hit,” he says. “A&E can pick up the blood and bruising, but the GP has that ability to talk to the patient.”
Residents of nursing homes are also at risk of abuse from both staff and from other residents.
“Physicians should be alert to this possibility when examining and treating nursing home residents, because clinically significant injuries have been found to result from resident-to-resident aggression,” the review states.
THE SIGNS OF ABUSE
The NSW Elder Abuse Helpline & Resource Unit, in its submission to the NSW inquiry, recommends that GPs should receive specialist training in detecting elder abuse, and that annual screening for elder abuse should be conducted by GPs.
But Dr Hindmarsh says there is no evidence GPs should routinely screen for elder abuse.
Screening is problematic because the high burden of chronic illness in older people creates both false negative findings (for example, fractures misattributed to osteoarthritis) and false positive findings (for example, spontaneous bruising misattributed to physical abuse), according to the review.
Rather than screening for elder abuse, Dr Hindmarsh says GPs should keep the possibility of elder abuse on their radar, and should be “case finding”.
When something rings an alarm bell about an elderly patient’s care, GPs can use the Canadian-developed Elder Abuse Suspicion Index (EASI), a validated and widely-recommended tool, to screen for abuse, she suggests. The index is detailed in the RACGP White Book, along with other resources.
The EASI index includes five questions about the patient’s care and circumstances during the past 12 months and one question aimed at doctors, highlighting signs of elder abuse such as malnourishment, cuts, bruises, or the patient being unusually withdrawn.
it is essential to raise the issue with the patient alone in the consultation.
“When elderly people become very frail, you should think about it,” Dr Hindmarsh says. “The most likely thing that a family will do is financial abuse – if the elderly person says they can’t afford their tablets or they haven’t got enough money for food, that should ring huge alarm bells.”
She says while patients are unlikely to tell the GP – or anyone – that they are being abused, they might frame it a different way or respond to a less direct question.
“You might ask if they are ever frightened of somebody,” she says. “They’re in a very difficult position because they’re dependent on other people like their family and so if they start complaining about them, they know they might get thrown in a nursing home and that is not what they want.”
She says it is essential to raise the issue with the patient alone in the consultation.
If a GP does suspect an elderly patient is a victim of any kind of abuse, Dr Hindmarsh suggests their first step should be to call the elder abuse line in their jurisdiction to discuss the patient’s situation, unless they are concerned about criminal activity in which case they may need to contact the police (see box, left).
She stresses that GPs do not “report” elder abuse to the helpline, but rather, call to discuss a patient’s situation and options.
“It is so nice to be able to talk with someone about it. It gives you support and ideas about how to get help for the person,” says Dr Hindmarsh.
In NSW, the Department of Family and Community Services funds Catholic Community Services NSW/ACT to operate its elder abuse helpline. The staff assess the needs of the older person, and refer them to services including legal services, health services, police, NSW Civil and Administrative Tribunal and Guardianship Divisions, community, housing and financial services, or to emergency services where needed. Helpline staff make referrals directly where the older person doesn’t have capacity or the confidence or expertise to do so themselves.
“If you are concerned about the care your patient is receiving and the patient has lost capacity, then it may get to a stage where you should go to the Guardianship Division to help sort out who should have enduring power of attorney (looking after finances) and who should be making the medical decisions (substitute decision maker),” she suggests.
A NEW ITEM NUMBER
In its submission to the NSW inquiry, AMA NSW states that GPs have a pivotal role in the recognition, assessment, understanding and management of elder abuse and neglect.
However, it warns there is a shortage
of funding to meet the training needs of those in the frontline across the sector, and a lack of MBS funding to enable GPs to provide such care.
It is calling for a new Medicare item number for GPs to liaise with social services, to cover the non face-to-face time they must spend to coordinate care, referral and services for patients experiencing abuse.
The journal review also highlights the complexity of intervening in situations where an elder person is being abused.
“Successful treatment rarely involves the swift and definitive extrication of the victim of abuse from his or her predicament with a single intervention,” that authors write. “Instead, successful interventions in cases of elder abuse are typically inter-professional, ongoing, community-based and resource intensive.”
The most important job for doctors is to recognise and identify elder abuse, and become familiar with the resources for intervention to which they can refer patients, as well as coordinating care with those resources.”
If care providers suspect that a nursing home resident that receives federal funding is being physically or sexually abused, there are mandatory reporting obligations under the Aged Care Act.
There is discussion, especially among legal circles, about whether such mandatory reporting obligations should be extended to cover all suspected elder abuse.
But Dr Hindmarsh is adamant such a move would prove disastrous.
She cites the failure of mandatory reporting of child abuse, saying she has had cases where a child disclosed abuse to someone at the practice, who was then obliged to report it authorities. However, the authorities failed to address the problem, leaving the child at even greater risk because their family knew they had spoken up about violence at home.
Exactly the same situation would arise if mandatory reporting was introduced for elder abuse, she says.
“I used to think mandatory reporting was the answer but the powers-that-be can’t cope with all the reports they get and these people will never come to the practice again. Where we could have worked with the child or the elderly person to get counselling or to help, they end up with no care and, I would suggest, added abuse.”
She says that doesn’t mean doctors can’t or don’t report cases of abuse at their discretion.
The Australian Association of Gerontology, in its submission to the NSW inquiry, warns that drawing on responses used in child protection is “ageist” and inappropriate.
“Mandatory reporting to government authorities of suspected elder abuse, irrespective of the older person’s wishes, is not consistent with respecting older people as autonomous adults,” it states.
Ian Day agrees mandatory reporting of abuse would only push it underground, but he believes there could be greater obligations placed on those who hold powers of attorney, enabling them to control the financial affairs of elderly people.
“There should be appropriate conditions and penalties if they do not fulfil their responsibilities of being a power of attorney,” he says.
Dr Hindmarsh says GPs are often in a position to identify if a person caring for their elderly spouse or parent is not coping, raising the risk of abuse.
“We need to work out how to make sure they don’t get burnt out – we’ve got to work out how to give them respite or get people in to help or get other family members to share the load,” she says.
And she points out that the previous relationship between an elderly person and their carer – be it their spouse or child – will impinge upon their care.
“For people who were previous abusers, then there is a real risk that people will get back at them for all the horrible things they did.’’
Mandatory reporting to government authorities of suspected elder abuse, irrespective of the older person’s wishes, is not consistent with respecting older people as autonomous adults.
CALLS FOR ACTION
The calls for action on elder abuse continue to grow, across legal, policing, medical and community arenas.
Aged Care Discrimination Commissioner Susan Ryan, in a speech to the Financial Service Council last October, said Australia needed a national response to stop older people falling victim to financial abuse and fraud.
“This terrible, destructive behaviour attracts too little attention. We need to focus on it much more strongly if we are going to develop more effective protections,” she said.
The Australia Longitudinal Study on Women’s Health urges more research to identify women most at risk, as well as further work with GPs to improve their ability to identify elder abuse.
And the Australian Association of Gerontology flags the idea of a “working with older people and or vulnerable adults check” process for nursing home staff, as raised in a recent inquiry into registered nurses in NSW.
Council on the Ageing believes there’s a need for more community education on the issue, along with the re-orienting of the NSW Elder Abuse Helpline and Resource Unit so it can work directly with the elder abuse victims, enabling them to “take the reins” to stop the abuse.
In its own submission to the NSW inquiry, the NSW helpline also recommends it be extended to include case management/coordination of elder abuse cases when required.
But underlying all those steps, Dr Hindmarsh believes there must be a change in our society’s attitudes to the elderly.
“These people need to be looked after and defended and they can’t do it themselves,” she says.
Megan Howe is a freelance medical writer