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
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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?
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Physical
Emotional
Financial
Sexual
Neglect and abandonment
Physical signs of abuse in an older person
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multiple bruising including bruising on well protected areas, for example
inner thigh, or bruising at different stages of healing
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finger marks
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burns especially in unusual places
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an injury similar to a shape or an object
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unexplained fractures
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inappropriate use of medication, for example, overdosing
Psychological signs of abuse in an older person
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appears depressed, frightened, withdrawn, apathetic, anxious or aggressive
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makes great efforts to please
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appears afraid of being, or unwilling to be treated by a specific member of staff
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appears afraid of a relative or carer
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displays fear or apprehension or distress before or after a visit from a relative,
carer or other visitor
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displays reluctance to be discharged to his, or her previous circumstances.,
particlularly if living with another person
Financial abuse
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unexplained withdrawals from a patient’s savings account
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an unexplained shortage of money, despite adequate income
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a sudden transfer of assets to a relative
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the disappearance of bank statements and valuables including jewellery, clothes,
personal possessions and money
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inability to explain what is happening to his or her income
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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
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pain, itching or injury to the anal, genital or abdominal area; bruising and
bleeding of external genitalia
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torn, stained or bloody underclothes
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venereal disease or recurrent bouts of cystitis
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unexplained problems with urinary catheters
Signs of neglect in an older person
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weight loss
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unkempt appearance, dirty clothing and poor hygiene
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pressure ulcers or uncharacteristic problems with continence
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inadequate nutrition and hydration
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inadequate or inappropriate medical treatment or withholding
treatment
Older peoples’ perception of
abuse
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Neglect – including isolation,
abandonment and social exclusion
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Violation of human, legal and
medical rights
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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?
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study of 250 family physicians and 250 hospital doctors
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72% reported no or minimal awareness of elder abuse and more than 50%
had never identified a case
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Most estimated abuse incidence at around 25% of correct figure
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over 60% had never enquired about abuse
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most would be reluctant to intervene
Nurses?
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potentially pivotal role in prevention, detection and
resolution
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awareness of abuse is not a mandatory part of pre or
post-registration nurse education nor mandatory for
National Vocational Qualification (NVQ)
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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?
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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?
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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
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social isolation – those who are abused usually have fewer contacts than
those who are not abused
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a history of a poor quality long-term relationship between the abused
person and the abuser
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a pattern of family violence because the abuser may have been abused as a
child
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the dependence of the abuser on the abused, for example, for
accommodation, financial and emotional support.
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a history of mental health problems, for example, a personality disorder,
or drug or alcohol problems in the person that abuses.
Institutional abuse
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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
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Abusive / assaultive behaviour eg
slapping, pulling hair, shaking
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Abusive treatments / practices eg
restraints, group bathing, public toileting
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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’
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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
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Adult Support and
Protection Bill
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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
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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
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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
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