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Elder Abuse

Older people present at health settings more often than younger people and frontline health staff may be the first to identify abuse of an older person. Abuse can occur anywhere, including the home, institutions or health care settings. It is estimated unreported cases of abuse, neglect and exploitation in NSW per year is 20,000 cases. It is predicted that almost four times as many incidents of abuse, neglect and exploitation are not reported and therefore 20,000 becomes 80,000 cases. Key issues for ED staff is that elder abuse does not discriminate, it’s hidden from view and can have serious physical injury and long term psychological consequences.


Definition

Written with thanks by Dr Nadia Bowman, reviewed by Dr Guru Nagaraj, as part of the ACEM Geriatric Special Skills Term at Hornsby Hospital. Contact Dr Clare Skinner, Director of Emergency Medicine for more details on clare.skinner@health.nsw.gov.au.

'Elder Abuse can be defined as 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. Elder abuse can take various forms such as physical, psychological or emotional, sexual and financial abuse. It can also be the result of intentional or unintentional neglect.’

(World Health Organisation, 2002)


Elder Abuse subtypes

Psychological Abuse

Inflicting mental stress via actions and threats that cause fear, violence, isolation, deprivation and feelings of shame and powerlessness. Examples include verbal abuse, intimidation and threats to put the older person into residential care. Social abuse (for instance, preventing contact with friends and family) can be treated as an example of psychological abuse or a separate subtype.

Physical Abuse

Non-accidental acts that result in physical pain or injury, or physical coercion.

Sexual Abuse

Unwanted sexual acts, including sexual contact, rape, language or exploitative behaviour, where the person's consent was not obtained or where consent was obtained through coercion.

Neglect

The failure of a carer or responsible person to provide life necessities, as well as the refusal to permit others to provide appropriate care. Some jurisdictions include self-neglect, but this is not universal.


Prevalence

Using these prevalence rates a clinician seeing 20 older patients/day may encounter a victim of elder abuse daily (Lachs and Pillemer 2004).

Elder abuse is largely preventable (unlike many conditions of old age).

Overall 1 year prevalence all types of abuse 2.2-36.2% mean 14.3%.

  • Physical mean 2.8%
  • Sexual mean 0.7%
  • Financial mean 4.7%
  • Emotional/psychological mean 8.8%
  • Neglect mean 14.3%.

Likely underestimate

  • Older adults under-report and downplay problems
  • Studies carry significant participation bias and exclude the most vulnerable groups e.g. dementia.

Risk factors for elder abuse

Limited knowledge of risk factors can be expected to contribute to poor detection. Many abuse risk factors have been identified:

Individual risk factors:

  • Functional dependence or physical disability
  • Poor health in general
  • Cognitive impairment, behavioral problems, psychiatric illness
  • Low income
  • Low levels of social support
  • Female gender
  • Family disharmony.

Perpetrator risk factors:

  • Caregiver depression/mental illness
  • Drug/substance misuse
  • USA/Israel/Europe perpetrator commonly spouse/partner
  • Asian perpetrator commonly children/children-in-law.

Protective factors:

  • Higher levels of social support and strong social networks.

Signs of Elder Abuse

Types of AbuseSigns Prevalence %
General
  • Frequent arguments or tension between the caregiver and the elderly person
  • Changes in personality or behavior in the elder
14
Physical
  • Unexplained signs of injury, such as bruises, welts, or scars, especially if they appear symmetrically on two side of the body
  • Broken bones, sprains, or dislocations
  • Report of drug overdose or apparent failure to take medication regularly (a prescription has more remaining than it should)
    • Broken eyeglasses or frames
    • Signs of being restrained, such as rope marks on wrists
    • Caregiver's refusal to allow you to see the elder along
3
Emotional

In addition to the general signs above, indications of emotional elder abuse include:

  • Threatening, belittling, or controlling caregiver behaviour that you witness
  • Behaviour from the elder that mimics dementia, such as rocking, sucking, or mumbling to oneself
9
Sexual
  • Bruises around breasts or genitals
  • Unexplained venereal disease or genital infections
  • Unexplained vaginal or anal bleeding
  • Torn, stained, or bloody underclothing
1
Neglect
  • Unusual weight loss, malnutrition, dehydration
  • Untreated physical problems, such as bed sores
  • Unsanitary living conditions: dirt, bugs, soiled bedding and clothes
  • Being left dirty or unbathed
  • Unsuitable clothing or covering for the weather
  • Unsafe living conditions (no heat or running water; faulty electrical wiring, other fire hazards)
  • Desertion of the elder at a public place
14
Financial
  • Significant withdrawals from the elder’s accounts
  • Sudden changes in the elder’s financial condition
  • Items or cash missing from the senior’s household
  • Suspicious changes in wills, power of attorney, titles, and policies
  • Addition of names to the senior’s signature card
  • Unpaid bills or lack of medical care, although the elder has enough money to pay for them
  • Financial activity the senior couldn’t have done, such as an ATM withdrawal when the account holder is bedridden
  • Unnecessary services, goods, or subscriptions
5

Elder Abuse Suspicion Index (EASI) - from elder abuse helpline toolkit

The EASI was developed to raise a doctor’s awareness about elder abuse to a level at which it might be reasonable to propose a referral for further evaluation by social services or adult protective services (such as the NSW Civil & Administrative Tribunal or NSW Police). While all six questions should be asked, a response of “yes” on one or more of questions 2-6 may establish concern. The EASI was validated for use by family practitioners of cognitively intact seniors in ambulatory settings.

The Elder Abuse Suspicion Index

EASI Questions

Q.1 – Q.5 asked of patient; Q.6 answered by doctor

Within the last 12 months:

1. Have you relied on people for any of the following: bathing, dressing, shopping, banking, or meals?

Yes No Did not answer

2. Has anyone prevented you from getting food, clothes, medication, glasses, hearing aids or medical care, or from being with people you wanted to be with?

Yes No Did not answer

3. Have you been upset because someone talked to you in a way that made you feel shamed or threatened?

Yes No Did not answer

4. Has anyone tried to force you to sign papers or to use our money against your will?

Yes No Did not answer

5. Has anyone made you afraid, touched you in ways that you did not want, or hurt you physically?

Yes No Did not answer

6. Doctor: Elder abuse may be associated with findings such as: poor eye contact, withdrawn nature, malnourishment, hygiene issues, cuts, bruises, inappropriate clothing, or medication compliance issues. Did you notice any of these today or in the last 12 months?

Yes No Did not answer

Interventions

Intervention If Elder Abuse is suspected or disclosed:

  • Make a referral to Social Worker who will complete a psychosocial assessment and coordinate appropriate interventions. If the situation were to present out-of-hours, the hospital on-call Social Worker should be contacted. If this is not available at your services, the patient may require overnight admission to ensure adequate assessment is made in daylight hours.

  • Do not alert or confront the alleged abuse (when and how this is done requires professional decision making between agencies on a case by case basis)
  • Everyone should take care of the safety of the older person, other vulnerable people, themselves and others.
  • Assess urgency and risk by considering: the need for medical attention; the danger to the older person or any other person; the nature and extent of the abuse (physical abuse and neglect are considered more urgent); the impact on the older person e.g. on mental health; the risk of repeated or increasing abuse; the relationship between the older person and the perpetrator. Alternatively use Elder Abuse Suspicion Index (EASI) as an assessment tool.
  • NSW Police or other emergency services should be contacted when required. It is preferable that the older person be consulted and provide consent for the report. However when significant risk to the older person or others is involved, confidentiality cannot be offered unconditionally.
  • Reporting to the Police is required regardless of victim’s view where: serious injuries such as broken bones have been inflicted; the perpetrator is threatening to cause physical injury to any person and have access to a gun; the perpetrator is using or carrying a weapon in a threatening manor; workers are threatened.
  • Staff should not engage in investigative questioning. This is the role of the police. Medical staff need to focus on questions related to the injury so that appropriate medical intervention is provided.
  • When abuse has occurred in a Residential Aged Care Facility, a mandatory report is to be made within 24 hours to Police on 1800 081 549.
  • If a report to NSW Police is not required then referral to Social Work should be considered so that a comprehensive psychosocial assessment is made. For the patient’s safety they may need to be either admitted or referred to ACAT and/or other specialist services e.g. Legal Aid, Guardianship Tribunal, Mental Health services.
  • Be supportive and protective reassuring the older person that responsibility for violence always lies with the perpetrator. Label the perpetrators’ behaviour as a crime and inform the older person of their right to pursue/ not to pursue, the crime with NSW Police to report the offence.
  • Talk to the older person alone without family/carer present alone. Social Worker should be present. Use familiar words and repeat questions. Allow extra time for responding and pace questions. Ask open questions to initiate conversations e.g. how are things going at home?
  • Document injuries and treatment given and other intervention provided. If the person does not seem to have capacity consider referral to geriatrician for assessment and decision on future care.

The 5–step approach to identifying and responding to the abuse of older people

STEP 1: IDENTIFY ABUSE (suspected, witnessed or disclosed)

STEP 2: ASSESS IMMEDIATE SAFETY

STEP 3: PROVIDE SUPPORT

STEP 4: INFORM MANAGER & DOCUMENT

STEP 5: RESPOND & REFER


Support and Referral Information

  • NSW Ageing and Disability Abuse Helpline: 1800 628 221. This service provides advice to services providers and anyone with a concerns of elder abuse. Available Monday to Friday, 9am -5pm.
  • Carer Gateway: 1800 422 737. This service provides information and resources to support carers.
  • My Aged Care (also for Aged Care Assessment Teams): 1800 200 422. This service provides access to information about aged care servicers in the home, residential care and respite.
  • NSW Civil and Administrative Tribunal (NCAT): 1300 006 228. This is the NSW Government specialist tribunal service for applications for guardianship or financial management, when the older person is unable to make a decision because of cognitive impairment or psychiatric illness.
  • Victims Support Line: 1800 633 063. This service provides confidential emotional support, practical information on how to access the Approved Counselling Scheme and information to victims of violent crimes about applying for compensation through the Victims Compensation Tribunal.
  • Relationships Australia: 1300 364 277. This service provides counselling, family dispute mediation and family support.
  • Mensline Australia: 1300 78 99 78. The service provides support to men who want to talk about their family and relationship concerns.

References and Resources

  1. Elder Abuse Suspicion Index (EASI)
  2. NSW Elder Abuse Helpline & Resource Unit - NSW Elder Abuse Toolkit
  3. NSW Health Policy on Identifying and responding to abuse of older people (PD2020_001)
  4. NSW Health Policy on Compulsory Reporting Protocol for Residential Aged Care Services (PD2019_049)
  5. NSW Interagency Protocol For Responding To Abuse Of Older People 2020
  6. NSW Interagency Protocol for responding to abuse of older people 2020

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