Elder abuse

As many as 5% of older UK adults have been verbally abused and 2% had been physically or financially abused, a 1992 study found. Manuela Moraru explains what elder abuse is and what has been done to tackle the problem

Older people are a big headache and a waste of scarce resources: the biggest favour you could do to me as an older people's organisation is to get them out of my hospital,” stated a Kenyan healthcare professional to the World Health Organization and the International Network for the Prevention of Elder Abuse (INPEA).¹

During the past 50 years, the problem of family violence has been considered in specific age groups. The first to be recognised were child and wife abuse, and it was only in 1975 that abuse of the elderly was acknowledged.¹ It was another 15 years before research gained political acceptance, and still more needs to be done before this problem is properly controlled.

What is elder abuse?

The definition of elder abuse, as adopted by INPEA and developed by Action on Elder Abuse in the United Kingdom, states: “Elder abuse is 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.”

Box 1 shows the types of elder abuse recognised by WHO.

Definitions may vary between different cultural groups, but regardless of its type or definition “elder abuse results in unnecessary suffering, injury or pain, the loss or violation of human rights, and a decreased quality of life for the older person.”¹

A difficult issue to address

With the rapidly ageing global population—the percentage of people aged 60 and over increased from 10% in 2000 to 21.4% in 2050, according to the United Nations predictions (http://esa.un.org/unpp/)—this problem could become even more important. So why are there difficulties in addressing the issue?

Ms Bridget Penhale, European regional representative of INPEA, thinks that “this is because reaching professionals more generally and getting them to recognise the problem is hard; individuals have to be at a certain level of readiness and awareness to be receptive to the issue.”

Lack of time, concern, knowledge, and awareness of elder abuse contribute to the perpetuation of this phenomenon and to its silent acceptance. Thus, education of professionals as well as the general public is essential. “If professionals and other workers involved with older people are not sufficiently trained about abuse they will not learn how to recognise it, nor know what to do about it,” said Ms Penhale.

Within the past decade there has been a concerted effort to get the issue on to the political and public agenda, but difficulties continue owing to ageism, the lack of status of older people, and other problems competing for attention. Getting people interested and concerned about the issue is hard and long term work, Ms Penhale says. “It is a long road to travel... and the journey is not yet complete.”

Acting on it seems difficult

Why? Firstly, because for many years there hasn't been a clear, internationally accepted definition of elder abuse, and classifying existing cases was therefore difficult.

Secondly, a wide variety of different methods of detection and assessment have been developed, such as the quick assessment methods used in busy environments (for example, the emergency room) or the long assessment forms used by adult protection services or for follow-up.²

The lack of an accepted definition of elder abuse and a single method of detection and assessment

have led to difficulties in estimating the frequency of elder abuse. This has created another barrier to the proper management of cases of elder abuse. The lack of accurate epidemiological data on its occurrence and of a clear definition have allowed healthcare professionals simply to ignore it. Finally, a standard form of management of elder abuse hasn't yet been established.² Thus, even if elder abuse is detected, healthcare professionals might be confused about what they should do about it.

What has been done?

Raising awareness

As already mentioned, one important problem is the lack of awareness of elder abuse. The establishment eight years ago of INPEA, which represents both developed and developing countries (32 countries are included on five continents), indicates that international concern about elder abuse is increasing. Their activities show firm actions aimed at increasing public awareness and knowledge of the problem and at promoting education and training of professionals in the identification, treatment, and prevention of elder abuse. INPEA also aims to stimulate research into the causes, consequences, prevalence, and prevention of elder abuse and neglect and to campaign further on behalf of abused and neglected elders (www.inpea.net).

HelpAge International, a global network of non-profit organisations working with and for disadvantaged older people world wide (www.helpage.org), has several publications on practical issues regarding the management of violence towards and abuse of older people.

At national level, several organisations are active, mostly in developed countries. Examples include Action on Elder Abuse (www.elderabuse.org.uk) and Age Concern (www.ageconcern.org.uk) in the United Kingdom, which provide information and resources for doctors and the public on related issues and act as resources for the media.

The US National Center on Elder Abuse (www.elderabusecenter.org) represents a gateway to resources on elder abuse and neglect and exploitation of the elderly, and it provides comprehensive guidelines on how to act if elder abuse is suspected.

The Canadian Network for the Prevention of Elder Abuse (www.cnpea.ca) dedicates its efforts to the prevention of abuse of older people in Canada. It strives to educate people on how to recognise abuse of older people and to inform and raise people's awareness of the issues and implications of abuse of older persons.

The Age Concern New Zealand elder abuse and neglect prevention service provides programmes for raising awareness and training on elder abuse and neglect, as well as coordinating responses to cases of abuse or neglect of older people (www.ageconcern.org.nz).

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Detection and assessment

At the same time as increasing awareness, extensive scientific work has been published, but unfortunately only a few studies give reliable data on detection and management to guide clinicians.³

The WHO Toronto Declaration on Elder Abuse⁴ adopted the current international definition of elder abuse and the types of abuse, aiming to eliminate important problems generated by the lack of a clear idea of what should be considered elder abuse.

Several methods and protocols for the detection and assessment of elder abuse have been developed during the past three decades. However, each of them has important limitations in terms of length

(methods taking more than one hour are impractical) and they have met resistance from healthcare providers and patients. Consequently, the quality of the collected data has decreased.² There has also been a failure to evaluate the structure of the questionnaires, usually based on Likert-type scales, which may introduce inconsistent and biased ratings as a result of different interpretations of the categories used. (A Likert scale is a type of psychometric scale often used in questionnaires. It asks respondents to specify their level of agreement to each of a list of statements (http: //en.wikipedia.org/wiki/Likert_scale)).

To overcome this important problem, WHO, in collaboration with a network of academic and other organisations such as the University of Geneva, McGill University, and INPEA, are developing a screening tool to help healthcare workers to identify suspected cases of elder abuse. In addition, they are building up public healthcare capacity to prevent and deal with elder abuse at community level, according to Dr Alexandre Kalache, the coordinator of the WHO ageing and life course (www.who.int/hpr/ageing). But more time is needed before the goals of this ambitious project are reached.

Intervention strategies

The Madrid International Plan of Action on Ageing 2002, adopted unanimously at the United Nations second world assembly on ageing, recognises the extent of the problem of elder abuse and proposes as objectives the elimination of all forms of violence, abuse, and neglect against older people and the establishment of sustaining services to address elder abuse (www.un.org/esa/socdev/ageing/waa/a-conf-197-9b.htm).

Even so, only a few countries include abuse of the elderly under their legal statutes and have fully developed systems for reporting and treating cases of abuse (www.who.int/hpr/ageing/elderabuse.htm).

In the United States, 44 states have legal requirements to report elder abuse and mistreatment to public agencies. Failure to report such cases may result in a fine or even loss of license.²

Canada has four main types of laws for protecting older adults from neglect and abuse: namely, family violence laws, criminal laws, adult protection laws, and adult guardianship laws, but none of them aims at prevention of the abuse or provides the abused person with support, assistance, and services (www.cnpea.ca).

In South Africa, legislation exists, but there are serious problems with applying it—that is, an unwillingness to report extremely high costs of the trials, and so on, as Ms Jané Joubert, specialist scientist of the Medical Research Council in South Africa burden of disease unit, confirms.

In Japan, one of the countries with the highest percentage of people aged over 60 years, specific laws on child abuse and domestic violence do exist, but there is still no law on elder abuse. However, during the past three years importance has been given to the issue by both governments and municipalities as well as by independent organisations, and media coverage of the problem has increased. Moreover, laws on elder abuse have been proposed and it is expected that these will be adopted soon, according to a statement from Dr Toshio Tatara, INPEA regional representative for Asia.

England, Wales, and Northern Ireland still have no separate laws that deal specifically with elder abuse or adult protection, and no major change in legislation is envisaged, Ms Penhale confirms. “Various laws exist within our jurisdiction, of course (eg, concerning theft, assault, etc) but nothing specific to protection from abuse.” Efforts to address the issue better are being made by professionals (predominantly from health and social care and latterly the police) together with several non-governmental organisations (such as, Action on Elder Abuse, Age Concern, Counsel and Care) which provide essential services for the abused elderly and advocate for the inclusion of the issue on the government policy agenda.

In Norway, a law for mandatory reporting wasn't considered necessary, but local authorities strive to ensure that services for abused older people are provided, following the Elder Protective Services recommendations (www.inpea.net/downloads/inpea-newsletter10.pdf )

With the lack of national laws specifically dealing with elder abuse, non-governmental organisations and social networks can be of use.

Taking action when abuse has been detected is a difficult task because of the lack of regulations concerning elder abuse. Even so, it should be a moral obligation of healthcare providers to do everything in their power to help abused persons.

What is the doctor's role?

The doctor's role is crucial in the detection, assessment, and treatment of elder abuse, especially when this relates to physical injury or sexual abuse, or both, resulting in trauma. In situations of emotional abuse, financial exploitation, or intimidation, doctors might also have a role in the recognition and identification of abuse and then referral, if necessary, to appropriate agencies and organisations that may provide help, Ms Penhale explains.

She points out that there “may also be an education role for physicians in discussion with the individual, to inform the person about abuse and violence and what might be done about it, as well as the education and training of other physicians and paramedical staff.”

Detection of elder abuse is obviously the first step in its management, just as the diagnosis is the first step in dealing with any other pathophysiological situation. Defining the typical characteristics of the abused and the risk factors for suffering abuse can be helpful in this process.

The abused person is usually frail and aged over 70 years, with more women affected than men (67% of the victims identified in the United Kingdom are women).⁵ It is generally accepted that the poor and women are more vulnerable to elder abuse.⁶ Box 2 includes several risk factors directly related to the elderly.

The specific characteristics of the abuser are equally important. Two major types were identified which correlated most frequently with different forms of abuse (box 3).

The main risk factors the carers introduce are possible pathological characteristics, in particular mental illness and alcohol misuse.

Finally, environmental and societal risk factors should also be considered (box 4).

WHO recommends routine screening by public healthcare workers when providing services to older people, and if abuse is suspected a systematic evaluation of the older person should follow. If the suspicion of abuse persists, the case should be reported (with the consent of the person concerned) to the organisation in charge of protecting older people, in countries where such an organisation exists, or referred to appropriate services (for example, social services).⁷ If the elderly person is in immediate danger, a safety plan is recommended (for example, admission to hospital or taking him or her to a safe place if they agree).

Elder abuse is an important issue that requires the attention of all healthcare professionals, and action should be taken without proof of the abuse and an established strategy on intervention. Relieving the suffering of the patient should be the main objective.

Action is needed now and at all levels, so that the situation can be improved. Elder abuse “is a problem that requires a multisectorial and multidisciplinary approach,” as Dr Kalache affirms.⁸  International and national strategies for prevention and intervention must be implemented, continuous training of professionals must be adequate, and awareness of the public must increase, “so that zero tolerance attitudes towards elder abuse can develop and prevention of it enhanced. Without ensuring this the issue could well “die” again, as happened in the 1980s,” Ms Penhale says.

Elder abuse is becoming more widely recognised, particularly within society in general, but we are a long way from dealing with it effectively. Establishing adequate systems of prevention remains a long term goal. Isn't it for all of us to contribute to this change?

1. World Health Organization and INPEA. Missing voices: views of older persons on elder abuse. Geneva: WHO, 2002.
2. Fulmer T, Guadagno L, Bitondo Dyer C, Connolly MT. Progress in elder abuse screening and assessment instruments. J Am Geriatr Soc 2004;52:297-304.
3. Nelson HD, Nygren P, McInerny Y, Klein J. Screening women and elderly adults for family and intimate partner violence: a review of the evidence for the US Preventive Services Task Force. Ann Intern Med 2004;140:387-96.
4. World Health Organization. The Toronto declaration on the global prevention of elder abuse. Geneva: WHO, 2002.
5. House of Commons. The United Kingdom Parliamentry Select Committee on Health. Minutes of evidence memorandum by Action on Elder Abuse, 2004. www.publications.parliament.uk/pa/cm200304/cmselect/cmhealth/111/3121102.htm
6. Wolf RS, Pillemer K. Helping elderly victims: the reality of elder abuse . New York: Columbia University Press, 1989.
7. World Health Organization. Elder abuse—a guide for primary health care workers. Geneva: WHO, 2002.
8. Kalache A, Perel Levin S. La OMS y la prevención del abuso de personas mayores. Revista Español de Geriatria y Gerontologia 2002;37:289-90.

   

           

	LIFE Elder abuse       Manuela Moraru (April 2006)
	Lukas A Holzer (April 7th)       medical student, Medical University of Vienna lukasholzer@gmail.com
	As stated in the Article by Manuela Moraru (1) demographic changes in the Western civilisation lead to an increased percentage of older people. Ageing and its associated effects will truly be a big problem in the 21st century. Especially for people within the health care system this is an important thought. Therefore it is really necessary to sensitize these people to this forthcoming problem, especially medical students. It is a broad problem and its solution affords multidisciplinary cooperation from politicians, lawyers, doctors and so on. In general old people should be treated with respect, as every human being. It is hard to believe that things like elder abuse happen. It's sad, but it's true. Education might be a necessary step to achieve improvements. It's definitely true that something has to be done. So therefore the least what you should do as a medical student, is to get used to problems associated with ageing before they suddenly hit you. Anyway don't close your eyes. Try dealing with it and even better, try to solve it. Moraru M. Elder abuse. studentBMJ 2006;14:133 - 176 April ISSN 0966-6494