Elder abuse

• Late Recognition: Elder abuse was not recognized in Australia as a significant issue until the late 1980s.
• Awareness Gap: Despite increased awareness, there remains a notable lack of understanding and recognition both among the general public and medical professionals, particularly in comparison to child abuse.

Research on Elder Abuse

• Significance of Research: Over the last 15 years, Australian research has identified elder abuse as a multifaceted problem with social, medical, and legal implications.
• Prevalence Estimates: Studies estimate that 3-5% of individuals aged 65+ who live at home experience some form of abuse, with 4-10% of those in aged care services affected.

State-Specific Responses

• South Australia & Queensland: These states fund specific agencies that directly address elder abuse.
• New South Wales & Western Australia: Initiatives focus on developing protocols that enhance collaboration across agencies and provide education for healthcare providers on identifying and managing elder abuse.
• Victoria: A comprehensive guide for health and community service professionals has been published to standardize understanding and responses to elder abuse.

Protocols and Current Case Management

• Agency Protocols: Most organizations working with older adults now have established protocols to identify, assess, and manage cases of elder abuse.
• Geriatric Health Services: Currently, geriatric health services, particularly Aged Care Assessment Teams (ACATs), manage the majority of elder abuse cases.
• Limited GP Involvement: General practitioners are less commonly involved in elder abuse cases, often due to factors such as:
  • Limited awareness or training specific to elder abuse.
  • Discomfort in handling abuse cases.
  • Time constraints in the primary care setting.
  • Concerns about potential legal ramifications of reporting or intervening in cases of abuse.

Definition of Elder Abuse

• Working Definition: Elder abuse is defined as any pattern of behavior causing physical, psychological, financial, or social harm to an older individual, typically within a relationship of trust.
  • Exclusion: Self-neglect and self-mistreatment are excluded from this definition.
  • Common Locations: Abuse may happen within the community, in residential aged care facilities, or in hospital settings.
  • Typical Abusers: Often family members (80-90%) who live with or are financially dependent on the elder.
  • Age Factor: While the majority of victims are aged 65+, younger adults with disabilities (e.g., multiple sclerosis) may also be at risk.

Categories of Elder Abuse

General behaviour	Being afraid of one or many person/sIrritable 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 Avoiding eye contact or eyes darting continuously Contradictory statements not from mental confusion Reluctance to talk openly
Physical abuse Involves actions that cause physical pain or harm, such as hitting, restraining, burning, or inappropriate medication use.	A history of physical abuse, accidents or injuries Injuries such as – skin trauma – bruising – skin tears – burns – bed sores, ulcers – unexplained fractures and sprains Signs of restraint (eg at the wrists or waist) Unexplained behaviour changes suggesting under-medication or over-medication Unusual patterns of injury Unexplained injuries Signs of physical coercion.
Sexual abuse	Bruising around the breasts or genital area Unexplained genital or urinary tract infections Damaged or bloody underclothing Unexplained vaginal bleeding Bruising on the inner thighs Difficulty in walking or sitting
Emotional abuse Encompasses actions causing emotional distress, including verbal threats, humiliation, isolation, and deprivation.	A history of psychological abuse Observable fear – Reluctance to talk, fear, anxiety, nervousness, apathy, resignation, withdrawal, avoidance of eye contact Rocking or huddling up Anxiety Withdrawal Avoidance of eye contact Loss of interest in self or environment Insomnia/sleep deprivation Unusual behaviour or confusion not associated with illness
Economic abuse Misuse of the older person’s assets or funds, which can include unauthorized access to bank accounts, forced changes to legal documents, or improper use of a power of attorney.	History of fraudulent behaviour or stealing perpetrated on the patient Sudden financial difficulties Missing bank cards Unexplained account withdrawals Lost valuables. Lack of money to purchase medication or food Lack of money to purchase personal items Defaulting on payment of rent or residential aged care facility fees Stripping of assets from the family home or use of assets for free
Neglect	– Poor hygiene, bad odour, urine rash – Malnourishment, weight loss, dehydration (dark urine, dry tongue, lax skin) – Bed sores (sacrum, hips, heels, elbows) – Being over-sedated or under-sedated – Inappropriate or soiled clothing, overgrown nails, decaying teeth – Broken or missing aids such as spectacles, dentures, hearing aids or walking frame – weight loss – dehydration – lack of medical aids (glasses, dentures, mobility aids).

Prevalence and Victim Demographics

• Estimated Rates: Approximately 3-5% of community-dwelling individuals aged 65+ suffer abuse, with rates increasing in aged care services.
• Gender Distribution: No significant gender differences in abuse rates, although women may be more commonly affected due to longer life expectancies.

Characteristics of Abusers

• Relationship to Victim: The majority of abusers are family members, such as spouses or adult children, who may depend financially on the elder.
• Socioeconomic Factors: While financial strain can contribute, elder abuse is seen across all economic, religious, and racial groups.
• Abuser Psychopathology: Substance abuse, psychiatric illness, and cognitive impairments are significant risk factors among abusers.

Key Risk Factors for Elder Abuse

• Increased Dependency: Older adults with physical or cognitive impairments are particularly vulnerable, as dependence on others can create power imbalances.
• Abuser Psychopathology: The presence of mental illness, alcoholism, or cognitive impairment in the abuser is often a primary factor in cases of elder abuse.
• Family Dynamics: Past family violence, generational conflicts, or a cycle of abuse from childhood may contribute to elder abuse.
• Carer Stress: Stress from caregiving duties, particularly when compounded by financial hardship, lack of support, and illness in the caregiver, may lead to abuse.
• Population Ageing: The increasing elderly population with age-related diseases (e.g., dementia) places added strain on family caregivers, heightening the risk of abuse.

Assessment Process for Elder Abuse

1. Evaluate Patient Capacity:
   • Ethical Considerations: Confirm the patient’s ability to make informed decisions.
     • Assessment requires patient consent
     • victim’s autonomy must be respected, particularly if they are competent to make decisions.
   • Ask about abuse only when the competent patient is alone.
2. If Patient Lacks Capacity:
   • Seek consent from the person legally responsible for healthcare decisions.
   • If the legal representative is the suspected abuser, consult an advocacy group for appropriate guidance.
3. Use of Elder Abuse Suspicion Index (EASI):
   • Consider using the EASI questionnaire if the patient is competent to answer questions about abuse.
4. Involvement of the Carer:
   • Talk to the carer, provided they are not the suspected perpetrator.
   • Identify another support person if the carer is involved in the abuse.
5. Patient Reluctance:
   • Understand that older adults may not disclose abuse due to fear of retaliation, guilt, or a desire to protect the abuser.
6. Conduct a Detailed Assessment:
   • Perform a thorough medical history, geriatric assessment, and document any injuries or concerns.

Elder Abuse Suspicion Index (EASI) Questions:

• Q1-Q5 (asked to patient): Assess dependence on others, access to essential items, experiences of shaming or threats, financial manipulation, and physical or unwanted sexual contact.
• Q6 (answered by doctor): Observe signs such as poor eye contact, withdrawn behavior, malnutrition, hygiene issues, or visible injuries in the last 12 months.

Barriers to Disclosure

• Lack of understanding of abuse.
• Fear of abuser’s retaliation.
• Guilt or protective feelings toward a family member who may be the abuser.

Role of the General Practitioner (GP)

• Nonjudgmental Approach: Cases are often complex, involving both the abuser and the victim as individuals with unmet needs.
• Identification of Abuse: GPs, due to their long-standing relationships with older patients, are ideally placed to identify signs of abuse.
  • The 75+ health assessment item enables screening for functional, psychological, and cognitive aspects that can aid in identifying abuse.
• Management Role: While GPs manage medical issues related to abuse, other aspects (e.g., legal, social support) may be better handled by a multidisciplinary geriatric team to avoid compromising the GP-patient relationship.

Management Strategies for Elder Abuse

• Goals of Intervention: Ensure the safety of the victim while aiming for minimal lifestyle disruption and respecting their autonomy.
• Multidisciplinary Involvement: Interventions often require a combination of medical, social, legal, and psychological support services.
• Decision-Making Autonomy: Competent individuals retain the right to decline interventions, even if it means remaining in the abusive environment.

Managing elder abuse

1. Safety and Immediate Response:

• Prioritize patient safety regardless of abuse type.
• If there is immediate risk:
  • For severe physical abuse, separation may be necessary.
  • Arrange hospital or aged care transfer, involving supportive family when possible.
  • Report cases of physical or sexual assault to the police.
• For non-immediate risk:
  • Engage non-abusive caregivers and state/territory helplines.
    • Queensland Elder Abuse Helpline (1300 651 192)
    • White Ribbon Australia
  • Consult with other healthcare professionals, consider respite care, or involve aged care facility managers if applicable.

2. Reporting and Documentation:

• Report abuse to the police in criminal cases, and to regulatory bodies in cases of malpractice or professional misconduct.
• For financial abuse or cases where the patient lacks capacity, involve the Public Guardian for advocacy or guardianship.
• Document all abuse suspicions, including quotes, injuries, and avoid documenting on-site if an employee is the suspected perpetrator.

3. Medical Interventions:

• Address underlying medical issues in both the victim and abuser, such as physical impairments or psychiatric conditions.
• Improving health and treating psychiatric/substance abuse issues can reduce abuse risk.

4. Community and Respite Services:

• Use community services like
  • home nursing
  • housekeeping
  • meals on wheels
• Provide respite options (in-home, day, or institutional) to manage carer stress and prevent neglect.
• Highly Dependent Victims: Respite care in nursing homes is often required when the victim has high dependency needs and caregiver stress is a primary factor.

5. Counselling and Psychological Support:

• Offer individual or family counseling to help victims cope and stay safe.
• Domestic violence-specific referrals may be needed, though many services focus on younger individuals, posing challenges for older adults.

6. Abuser Treatment:

• Hospital Admission: In cases where mental health or substance issues are significant, hospitalizing the abuser may be necessary for treatment.
• Psychological Counseling: This can help the abuser understand and address their behavior, potentially reducing future abusive actions

7. Legal Measures:

• Immediate Legal Action: Criminal charges may be necessary in cases of financial or severe physical abuse, especially if there’s a history of domestic violence.
• Mainstream Legal Services: Competent older adults may need legal help (e.g., power of attorney) to protect their assets or evict an abusive person.
• Protection Orders: Police or magistrates can assist with restraining orders (e.g., Apprehended Violence Order) for the victim’s protection.
• Guardianship Applications: When the victim is unable to make decisions, applications to a guardianship board or tribunal may be necessary to ensure their safety and wellbeing.

Conclusion

• Growing Need for Awareness: The aging population and increased dependency levels are likely to lead to more cases of elder abuse.
• Comparative Reluctance: Unlike child abuse, elder abuse has not garnered as much involvement from the medical profession, particularly among GPs.
• GP’s Central Role: GPs are uniquely positioned to contribute to identifying, assessing, and managing elder abuse, highlighting the need for increased training and awareness within the medical community.