Elder Abuse
This Clinical Information Sheet has been developed to raise awareness of RACF staff, medical practitioners and relevant professionals working in residential aged care about elder abuse, and how to identify and respond to suspected cases of elder abuse.
This CIS covers:
About Elder Abuse Types of Elder Abuse Assessment; Management; Preventative Strategies; and Sources of Information Reference Cards:
Elder Abuse Suspicion Index
Elder Abuse Action Flowchart
This clinical information sheet is a guide only. It should be used with consideration to the:
Resident’s preferences, existing medical care plans, and Advance Care Plan; Health professional’s role, knowledge, preferences and professional experience; Policies and resources available within the RACF; Requirements of local professional registration and regulatory bodies; and Relevant local legislation.
About Elder Abuse
Elder abuse is a term referring to any knowing, intentional, or negligent act by a caregiver or any other person that causes harm (physical, psychological, financial or social) or a serious risk of harm to a vulnerable adult, where the older person and the person carrying out the action or behaviour are in a relationship which involves trust, dependency or proximity. It is also defined in terms of abuse of human or civil rights [1-5].
Abuse can occur in any culture, social and economic strata whenever there is an imbalance of power. It may occur in aged care facilities because the frailty of elderly residents renders them unable to defend themselves.
The Australian Society of Geriatric Medicine in their Position Statement on Elder Abuse (2003) estimates a 3-5% incidence of elder abuse in the community, as does the Victorian Elder Abuse Prevention Project (2005) [5]. There are no reliable national statistics to confirm the size of the problem in RACF [2]. The National Elder Abuse Incidence Study 1998 results indicate that over five times as many new incidents of abuse and neglect were unreported than those that were reported [1]. The ageing of Australia’s population and the increasing numbers of adults with dementia contribute to the anticipated growth in elder abuse cases in the future [5].
In Australia, the Federal Department of Health, Office of Aged Care Quality and Compliance reported 967 complaints (not necessarily abuse) in the year 2003-2004 to the Senate Committee of Inquiry, 97% of which involved residential aged care services. These figures do not include complaints made to State complaints bodies and advocacy groups [6]. Retribution, real or perceived is a significant deterrent to reporting a complaint and this obscures the real incidence. During the period 1999-2002, in 4,365 complaints records the words ‘fear’, ‘intimidation’, ‘retribution’, ‘reprisal’, ‘harassment’ or ‘victimisation’ were used [7].
Systemic problems identified as contributing to elder abuse within Australia include:
Underfunding resulting in understaffing, undertraining and lack of education about elder abuse [4, 7]; State/Federal complaints jurisdiction — demarcations are often unclear [7]; No-fault policy of official complaints scheme based on mediation between abuser and abused. No official recognition of psychopathic behaviour [6]; Lack of protective legislation with consequent lack of police powers for the majority of cases of elder abuse; and Lack of transparency in complaints system overall and in responses to individual complaints [7].
The Role of the GP
The GP is often the first independent professional to see an elderly victim of abuse; yet physician reports account for only 2% of elder abuse reports [4, 8]. There are a number of reasons cited as to why medical practitioners have not been more involved in managing cases of abuse. These include lack of awareness of the problem, discomfort at dealing with cases of abuse, lack of time, and fear of legal action. The findings of surveys suggest that research-based education and training would help GPs to become better at identifying and managing elder abuse [4, 5, 9].
Types of Abuse
Types of abuse include [1, 2, 4, 10]:
Physical abuse: Defined as inflicting, or threatening to inflict, physical pain or injury on a vulnerable elder, or depriving the person of a basic need; Emotional abuse: Inflicting mental pain, anguish, or distress on an elder person through verbal or nonverbal acts; Sexual abuse: Refers to non-consensual sexual contact of any kind; Exploitation: The illegal taking, misuse, or concealment of funds, property, or assets of a vulnerable elder; Neglect: The refusal or failure by those responsible to provide food, shelter, health care (including analgesia or dental care) or protection for a vulnerable elder; and Abandonment: The desertion of a vulnerable elder by anyone who has assumed the responsibility for care or custody of that person.
Examples of acts that constitute elder abuse are included in Table One.
Table One: Examples of elder abuse
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Type
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Examples
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Physical
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Slapping, pushing, burning, physical restraint, inappropriate use of medication
|
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Emotional
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Verbal intimidation, threats, shaming, loss of privacy, humiliation, loss of dignity, harassment, isolation, deprivation, withholding of affection
|
|
Sexual
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Rape, indecent assault and sexual harassment
|
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Exploitation
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Appropriation or concealment of funds, property, or assets. Improper changes to or use of legal documents such as power of attorney, wills
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Neglect
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Poor hygiene, poor personal care, presence of bedsores, lack of social, cultural, intellectual or physical stimulation
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Abandonment
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Leaving the elder with no means to care for self
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Assessment
A significant risk factor for elder abuse is dependency caused by physical impairment including medical diagnoses such as dementia, mental illness, stroke, sensory impairment, or intellectual impairment [2-4]. Because the majority of residents have some form of dependency (e.g. 60% of residential care residents have cognitive impairment), the GP and RACF staff should be alert to the possible occurrence of elder abuse [4].
Elder abuse may be misdiagnosed as depression, paranoia or dementia (a complaint of sexual assault is often attributed erroneously to dementia).
If the possibility of abuse is suspected or concern is raised, observe the emotional reactions and body language of the older person and the care-giver during conversations and observe the face to face interactions between the two.
A history should be taken from the resident by the doctor in private without other staff present because of the fear of retribution. Beware if the history or findings are inconsistent with the explanation given by staff, or if conflicting explanations are given by different staff members [2].
Ask the resident direct questions, and for permission to report the information to (where appropriate) the RACF management, relatives and/or through official complaints mechanisms. Disclosure of information must be taken case by case; privacy constraints are overcome where the doctor believes a crime has been committed or if it is in the patient’s best interests to do so.
Signs and symptoms
General behaviours that a person experiencing abuse may exhibit include [2-4]:
Afraid of one or many person/s; Irritable or easily upset; Worried or anxious for no obvious reason; Depressed, apathetic or withdrawn; Change in sleep patterns and/or eating habits; Rigid posture and avoiding contact; Contradictory statements not from mental confusion; and Reluctance to talk openly.
Signs and symptoms of physical abuse include [2-4]:
A history of physical abuse or accidents or injuries; Injuries such as skin trauma including bruising, skin tears, burns, welts or fractures, bed sores, ulcers; and Signs of restraint at the wrists and or waist.
Signs and symptoms of sexual abuse include [2-4]:
Bruising around the breasts or genital area; Unexplained genital infections; Damaged or bloody underclothing; Vaginal bleeding not associated with menses; Bruising on the inner thighs; and Difficulty in walking or sitting.
Signs and symptoms of psychological abuse include [2-4]:
A history of psychological abuse; Reluctance to talk, fear, anxiety, nervousness, apathy, resignation, withdrawal, avoidance of eye contact; Rocking or huddling up; Loss of interest in self or environment; Insomnia/sleep deprivation; and Paranoid behaviour or confusion not associated with illness.
Signs and symptoms of neglect include [2-4]:
History of neglect; Poor hygiene, bad odour, urine rash; Mal-nourishment, weight loss, dehydration(dark urine, dry tongue, lax skin); Bed sores (sacrum, hips, heels, elbows); Over or under sedated; Inappropriate or soiled clothing, overgrown nails, decaying teeth; and Broken or missing aids such as spectacles, dentures, hearing aids or walking frame.
Elder Abuse Suspicion Index
The Elder Abuse Suspicion Index was developed from research conducted on cognitively intact seniors in an ambulatory setting by Yaffe et al [11]. “The goal is to have a reasonable level of suspicion to justify referral to an appropriate community expert in Elder Care. Questions aim for suspicion, not necessarily a diagnosis….”. [11]
The Elder Abuse Suspicion Index is included as a reference card [4, 11]. A positive response to any of questions 2-6 on the index should be viewed as adequate to generate suspicion of elder abuse. It is more practical to implement by GPs than the “gold standard” Social Workers Evaluation, which takes over 60 minutes to administer.
The Elder Abuse Suspicion Index has been adapted by the World Health Organization [4]. The index was rated by 72/104 general practitioners who used the tool in hospital or community settings as follows [11]. Table Two depicts the ratings GPs gave the index.
Table Two: GP rating of Elder Abuse Suspicion Index
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Rating Statement
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% GPs agreed
|
|
Somewhat /very easy to use
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95.8
|
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Less than 2 minutes to use
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67.6
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Some - big practical impact
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97.2
|
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Increased awareness of Elder Abuse
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66.0
|
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Increased confidence what to look for
|
64.0
|
|
Somewhat / very, practical, useful
|
81.5
|
Profile of an Abuser
An abuser may be another resident (commonly with dementia), a staff member (including volunteers), visitor or family member.
Understanding factors that can increase the chance a person may abuse a vulnerable elder can provide direction for intervention and preventive strategies [5]. Abuse between residents may occur if there is inadequate separation of residents who may be a danger to others. Carers with mental illness or limited stress coping skills are more at risk of abusing. Other risk factors are lack of training, and fatigue due to insufficient staff.
Factors to consider in assessing a suspected abuser and appropriate intervention strategies include their [3]:
Motivation e.g. greed, drug/alcohol abuse, psychiatric illness, caregiver stress; Behaviour e.g. aggression, blaming others, stress, fatigue; Physical and mental condition e.g. psychiatric illness; and Response to the situation e.g. does he/she acknowledge the abuse; is he/she willing to accept help.
Management
Management includes:
Action will depend on the degree of suspicion or evidence that abuse has occurred, seriousness of the abuse, the immediate danger to the older adult, the abuser’s profile, and available support mechanisms.
If there is reasonable suspicion of elder abuse action should be taken. In most instances RACF staff should report suspicion of elder abuse to senior RACF staff or the resident’s GP, however this will depend on who is identified as the suspected abuser.
A flow chart in the reference cards provides suggested courses of action.
Urgent action
In emergency situations where abuse is identified and there is an immediate threat to the victim, consideration to the following may be necessary [3]:
Safety of others (e.g. is the abuser violent or likely to abuse other residents; Protection of the victim; Treating injuries; and Arranging emergency accommodation.
Notify the police if criminal action has occurred or is occurring such as sexual or serious physical assault. In that case any notification or questioning is done by the police. In treating the resident’s injuries, be careful not to disturb evidence in criminal cases. Consider transferring the resident to an acute hospital bed or respite in another facility if required. Fear of retribution is a real fear [6]. Notify the coroner if a death has occurred following an incident of elder abuse.
Counselling
Support and counselling may be needed by the victim, the resident’s family, RACF staff and the abuser.
Documentation
Any report or suspicion of abuse should be clearly documented, including quotes from the resident and staff and photographs of injuries. Documentation in the resident’s progress notes is usually inappropriate and should be kept off the premises, e.g. at GP’s surgery, however this may vary depending upon the identity of the suspected abuser.
Reporting Elder Abuse
There are a variety of reporting mechanisms that may be appropriate, depending upon the specific circumstances, particularly the type of abuse, location and suspected abuser.
Cases of a criminal nature
If there is suspicion that a crime (e.g. assault, theft, extortion, fraud, sexual offences) has occurred or if protection is required for the victim or any other people involved, the police should be notified [3]. The police or the Magistrate’s Court can be contacted if there is reason to apply to the Magistrates Court for an intervention order under Section 7 of the Crimes (Family Violence) Act 1987 [3], e.g. if the perpetrator is a family member.
Cases relating to professional malpractice
The Victorian Health Services Commissioner has the power to investigate complaints relating to providers of health services, such as GPs, nurses and allied health professionals [3] and should be contacted in cases relating to professional malpractice. Problems arising from staff conduct also come under State jurisdiction and may be reported to the appropriate professional body, e.g.Medical Board, the Nurses Board Victoria. Cases relating to administrative staff and/or administration of staff, e.g. staffing numbers, come under Federal jurisdiction. Advocacy groups provide support in making a report to the correct complaints body.
Cases relating to the RACF
The Federal Department of Health Office of Aged Care Quality and Compliance deals with policies and procedures concerning standards of care in the RACF and can be contacted regarding known or suspected abuse occuring within a RACF. In addition the Health Services Commissioner of Victoria is responsible for investigating complaints relating to elder abuse that are related to health services, including RACFs, GPs, ambulance services and other health professionals [3]. The Residential Care Rights Service is a Victorian advocacy body available to assist in managing complaints related to the RACF. Whilst this body does not have powers to investigate cases of elder abuse they will advocate on the victim’s behalf and assist in making an official complaint if the older adult is prepared to assist in the process [4].
Cases requiring guardianship intervention
If the case relates to an older adult who is incapable of making reasonable decisions, e.g. due to dementia, the matter may be referred to the Office of the Public Advocate for investigation or advocacy. The Public Advocate is able to refer matters to the Guardianship and Administration Board where the older adult requires a guardian or administrator, e.g. if abuse by a family member is suspected. If required the Guardianship and Administration Board may appoint a family member, friend, solicitor, accountant or trust company as the person’s decision maker and financial representative [3].
Preventive Strategies
Due to their reduced physical and/or cognitive capabilities, residents of aged care facilities are at an increased risk of becoming victims of elder abuse. RACF staff members are at an increased risk of becoming perpetrators of abuse due to work-related stress [2-4]. In addition, GPs and RACF staff members are in a position where they may encounter elder abuse perpetrated by family, visitors, residents, staff members or health practitioners in the facility. By initiating preventative strategies within the facility, the risk of elder abuse may be reduced [3].
Staff Education
All RACF staff members should receive regular education on care-giving, particularly areas known to provoke caregiver stress, e.g. dementia care and behaviour management. Increasing the ability of staff members to manage difficult care giving situations may reduce the risk of elder abuse [3].
Providing staff members with the skills to identify and address their own stress factors may prevent abuse arising. In addition, RACF managers should consider referring individual staff members to appropriate counselling and support services, e.g. drug and alcohol treatment program, stress management, where risk factors are identified [3].
RACF staff members should also receive training in the identification of elder abuse and action to take as a caregiver responsible for the safety of the resident.
Resident support
Programs designed to assist residents in identifying abuse, to develop safety and coping strategies, which increase the resident’s access to support from other residents and professional counsellors may help reduce the incidence of elder abuse within RACFs [3]. All residents entering aged care facilities should be provided with information about elder abuse and resources available to support victims. Information should be readily available and accessible without fear of repercussion.
Sources of Information
Where to go for more information
Elder Abuse Prevention Association
Established in 2002, the Elder Abuse Prevention Association raises public awareness and advocates for the safety and welfare of older persons in the community. The association also provides services for older persons who are abused, neglected, and/or exploited.
Contact for all enquiries: (03) 8562 2202
Website: http://www.eapa.asn.au/
Federal Department of Health, Office of Aged Care Quality and Compliance
Responds to and aims to resolve complaints about the care of residents in aged care facilities, as well as residents receiving Aged Care packages.
Aged and Community Care Branch
Department of Health and Ageing (Commonwealth)
2 Lonsdale Street, Melbourne 3000
Telephone: (61 3) 9285 8888 or 1800 550 552 Free call
Health Services Commissioner
Investigates complaints relating to health care services, including residential aged care facilities, as well as providers of health services, such as GPs, nurses and allied health professionals.
Telephone: (61 3) 8601 5200 Toll Free: 1800 136 066
Office of the Public Advocate
OPA investigates cases of people with a disability, including dementia, who are at risk of or experiencing abuse, exploitation and/or neglect. OPA manages a telephone advice service, which can also provide referral to relevant agencies.
Telephone: (03) 9603 9500 Toll Free: 1300 309 337
Residential Care Rights
Residential Care Rights Service is an advocacy service for people receiving a Commonwealth funded aged care in Victoria. The service provides education for staff, residents or interested parties on elder abuse and will assist in reporting elder abuse where the resident is prepared to assist in any investigations. This group also offers education and counselling programs (some free of charge) for RACFs.
Suite 4B, 343 Little Collins Street,
Melbourne VIC 3000
Telephone: (03) 9602 3066 Toll Free in Victoria except from mobile phones: 1800 700 600
Website: http://www.sa.agedrights.asn.au/rcr/home.html
Further reading
In addition to the references, the following resource is recommended:
New South Wales Advisory Committee on Abuse of Older People in their Homes training package called ‘Behind Closed Doors: Abuse of Older People in their Homes’ (1995). The education kit contains a video, handbook on assessing and managing abuse of older people, case scenarios, and a Legal Issues Manual.
References
National Centre on Elder Abuse , (NCEA), Elder Abuse FAQs: Washington. Elder Abuse Prevention Unit, (EAPU), Elder Abuse Prevention Unit, in http://www.eapu.com.au, Elder Abuse Prevention Unit, (EAPU) and Lifeline Brisbane, (LLB). 2005 Victorian Health and Community Services, (HCS), With Respect to Age: A Guide to Health Service and Community Agencies Dealing with Elder Abuse. 1995, Melbourne: Aged Care Services Victoria. Victorian Community Council Against Violence, (VCCAV). Preventing elder abuse through the health sector. 2005, Victorian Community Council Against Violence: Melbourne. p. 41. Elder Abuse Prevention Project, (EAPP). Strengthening Victoria’s Response to Elder Abuse. 2005, Elder Abuse Prevention Project, (EAPP). Melbourne. p. 48. The Senate Committee of Inquiry, (SCI), Quality and equity in aged care report. 2005, Australian Federal Government: Canberra. Hogan, W., Review of Pricing Arrangements in Residential Aged Care. 2004: Canberra. O'Brien, J.G., Elder abuse and the physician. Mich Med, 1986. 85: p. 618-620. McCreadie, C., Bennett, G., Gilthorpe, M., Houghton, G., Tinker, A., JRSM, 2000. 93(2): p. 67-71. ACT Office of Ageing, (ACTOA), Elder Abuse Prevention & Assistance , in http://www.ageing.act.gov.au/elderabuse/community_and_professional_education, Government, ACT. 2006 Yaffe, M.,al, et, verbal correspondence. 2006 National Health And Medical Research Council, (NHMRC), Guidelines for the development and implementation of clinical practice guidelines. 1995, Canberra: AGPS.
Levels of Evidence
Background information on elder abuse provided in this Clinical Information Sheet (CIS) is based on opinions of experts in the field, particularly recent publications by the Victorian Community Council Against Violence and the Elder Abuse Prevention Project, as well as information provided by Victorian Health and Community Services.
The following table outlines the level of evidence of each reference:
|
|
Reference |
Year |
Level of Evidence |
1. |
National Centre on Elder Abuse , (NCEA), Elder Abuse FAQs: Washington. |
|
Level V evidence |
2. |
Elder Abuse Prevention Unit, (EAPU), Elder Abuse Prevention Unit, in http://www.eapu.com.au, Elder Abuse Prevention Unit, (EAPU) and Lifeline Brisbane, (LLB). 2005 |
2005 |
Level IV C evidence |
3. |
Victorian Health and Community Services, (HCS), With Respect to Age: A Guide to Health Service and Community Agencies Dealing with Elder Abuse. 1995, Melbourne: Aged Care Services Victoria. |
1995 |
Level IV C evidence |
4. |
Victorian Community Council Against Violence, (VCCAV). Preventing elder abuse through the health sector. 2005, Victorian Community Council Against Violence: Melbourne. p. 41. |
2005 |
Level IV C evidence |
5. |
Elder Abuse Prevention Project, (EAPP). Strengthening Victoria’s Response to Elder Abuse. 2005, Elder Abuse Prevention Project, (EAPP). Melbourne. p. 48. |
2005 |
Level IV C evidence |
6. |
The Senate Committee of Inquiry, (SCI), Quality and equity in aged care report. 2005, Australian Federal Government: Canberra. |
2005 |
Level IV C evidence |
7. |
Hogan, W., Review of Pricing Arrangements in Residential Aged Care. 2004: Canberra. |
2004 |
Level IV C evidence |
8. |
O'Brien, J.G., Elder abuse and the physician. Mich Med, 1986. 85: p. 618-620. |
1986 |
Level IV C evidence |
9. |
McCreadie, C., Bennett, G., Gilthorpe, M., Houghton, G., Tinker, A., JRSM, 2000. 93(2): p. 67-71. |
2000 |
Level IV C evidence |
10. |
ACT Office of Ageing, (ACTOA), Elder Abuse Prevention & Assistance , in http://www.ageing.act.gov.au/elderabuse/community_and_professional_education, Government, ACT. 2006 |
2006 |
Level IV C evidence |
11. |
Yaffe, M.,al, et, verbal correspondence. 2006 |
2006 |
Level V evidence |
Literature was identified through a standardised search for systematic reviews and clinical guidelines published by relevant health organisations; and ‘clinical guidelines’ and ‘practice guidelines’ in CINAHL & MEDLINE databases and HONcode search engine. Literature was evaluated according to relevance to residential aged care patients, and strength of evidence using an adapted version of the NHMRC (1995) [12] scale for randomised control data and lower levels of evidence when RCT is not available. The scale was adapted by adding a level of evidence (level V) for non-referenced material, eg developed in local RACFs.
Applicability of information
This Clinical Information Sheet has been developed with consideration to legislation and any requirements of or recommendations from professional registration groups or regulating bodies (e.g. NBV, RCNA, ANF) overseeing the residential aged care industry in Victoria, Australia. Readers outside Victoria, Australia are advised to review the material in the context of their local legislation and health system regulations.
This Clinical Information Sheet was developed using the process outlined in Section 5, and is provided under the terms of the disclaimer in Section 1 of the GP and Residential Aged Care Kit.
GP and Residential Aged Care Kit: http://nwmdgp.org.au/pages/after_hours/
For more detailed or up to date information than is provided in this CIS, please refer to cited sources and current literature.
Reference Cards for Elder Abuse
The following reference cards are designed to be used in conjunction with the Elder ABuse Clinical Information Sheet. Because the evidence base and availability of national guidelines for clinical care and multidisciplinary service delivery is rapidly changing, we strongly recommend that the these Reference Cards be regularly reviewed and revised as with Clinical Information Sheets.
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Reference Cards:
Elder Abuse Suspicion Index
Elder Abuse Action Flowchart
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