Abuse of older people

The abuse of older people is a significant public health problem, and is linked to increased mortality and disability.¹

This is made clear by the recent Royal Commission into Aged Care, which investigated neglect and abuse of older people in Australia. The summary report states that ‘substandard care and abuse pervades the Australian aged care system’, and that the abuse carried out in these settings ‘should be a source of national shame.’² In addition, the interim report suggests ‘a shocking tale of neglect of older people’ in Australia, stating, ‘At the heart of these problems lies the fundamental fact that our aged care system essentially depersonalises older people’.³

In 2018, there were an estimated 3.9 million older Australians (aged 65 years or older), equivalent to 16% of the population (Figure 15.1). This was an increase from 2.9 million people (13% of the population) in 2009. Very old Australians (aged 85 and over) accounted for 2.0% of the population in 2018, and this proportion is projected to increase to 4.4% by 2057.⁴

The increasing number of older people and the changing characteristics of the ageing population are associated with a range of issues. These include:

• implications for high-level aged care
• a need for policies and services that respond to the needs of this population and support healthy, positive ageing
• the potential for social isolation and abuse of older people.⁵

In the words of the Australian Law Reform Commission report: ‘Ageing eventually comes to all Australians, and ensuring that all older people live dignified and autonomous lives free from the pain and degradation of elder abuse must be a priority’.⁶

Furthermore, the concept of healthy ageing should inspire a new focus for healthcare in older people. This involves optimising people’s intrinsic capacity and functional ability as they age.⁷

Figure 15.1. Proportion of Australians aged 65 years and over⁴

Source: Australian Institute of Health and Welfare.

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Definitions

Note that the term ‘abuse of older people’ has been chosen over ‘elder abuse’ in this chapter in deference to Aboriginal and Torres Strait Islander peoples, for whom the title of ‘elder’ has such cultural significance. However, the term ‘elder abuse’ is used widely in the published literature on this topic.                           

Abuse of older people is defined as any type of abuse or neglect of people aged 65 years or over. Types of abuse include:⁸

• physical
• emotional and psychological
• sexual
• financial
• neglect

The abuse or neglect can be 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.¹

Prevalence

The World Health Organization (WHO) estimates the incidence of abuse of older people to be about one in six, and suggests that it is generally a hidden problem.¹

A 2017 meta-analysis of studies from 28 countries estimated that 15.7% of people aged 60 years and older were subjected to some form of abuse over the past year.⁹ There is some evidence that rates of abuse are higher in institutional settings compared with community settings.¹

Older women experience violence and abuse at two and a half times the rates of older men; 20–25% of these incidents are intimate partner abuse/violence (IPAV), with women particularly vulnerable if their partner has a duty of care relationship with them.¹⁰ IPAV in older people is often a continuation of ongoing abuse; violence against older women exists in the margins between domestic violence and abuse of older people, with neither field adequately capturing the experiences of older women who are victims/survivors of IPAV.¹⁰  

In Australia, the prevalence of abuse in the older population is estimated to be between 2% and 14%, with neglect possibly occurring at a higher rate.⁴ However, there has been a lack of research in the areas of prevalence and management. Australia’s first national prevalence study of abuse of older people commenced in 2019 and is expected to provide data to guide the national response to abuse of older people.  

In 2018 there were an estimated 219,000 Australians with dementia, which is a risk factor for abuse.⁸ Females, with a prevalence of 1.0%, were more likely than males to have the condition (0.8%).¹¹

Where does abuse happen?

Abuse of older people occurs in all cultural and socioeconomic strata whenever there is an imbalance of power.¹

Abuse may occur to an elderly person being cared for by family or community services, or in a residential aged care facility or hospital.

Perpetrators can be family members or carers; in the case of older persons in residential care, the abuser may be another resident (sometimes with dementia), a staff member (including volunteers), visitors or family members.

Abuse of older people may occur for many reasons, including individual, relationship, community and sociocultural factors (see below). For example, where a child is caring for a parent, there might be a change in roles where the carer becomes the ‘parent’ and the ‘parent’ becomes the ’child’. This increasing dependency, sometimes accompanied by responsive behaviour in people living with dementia, can be frustrating and act as a catalyst for abusive behaviour by the carer, particularly if the carer is insufficiently supported. Relationships Australia provides a factsheet on how to identify warning signs of abuse of older people.

Abuse of older people in specific populations

There is a lot of variation in how different cultural groups respond to the abuse of older people. In Australia there is limited research about the abuse and neglect of older people among culturally and linguistically diverse groups and Aboriginal and Torres Strait Islander communities, but there is some evidence to suggest that they are particularly vulnerable to financial abuse.⁴

Aboriginal and Torres Strait Islander people make up 3% of the total population, and about 3% of this population were over 65 in 2017. Aboriginal and Torres Strait Islander people are entitled to aged care services from the age of 50, due to their shorter life expectancy.⁴ One in five older Aboriginal or Torres Strait Islander people live in rural and remote Australia with limited services.¹² Much of their care is carried out by family members.¹³

Refer to Case study 15.2 and the chapters on migrant and refugee communities and Aboriginal and Torres Strait Islander peoples.

Risk factors

A number of risk factors, associated with both the older person and with their carer/s or other people of trust, can increase the potential for abuse of an older person. These risk factors relate to the individual, relationship, community and society level. Figure 15.1 shows how these risk factors fit into an ‘ecological’ approach to identifying, managing and preventing abuse of older people. 

Figure 15.2. Applied ecological approach to abuse of older people¹⁴

Source: Joosten M, Vrantsides F, Dow B. Understanding elder abuse. A scoping study. Melbourne: Melbourne University and National Ageing Research Institute, 2017:1092–110.

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An ecological approach can be applied to abuse of older people, where factors at the individual, close relationships, community and societal level all are considered.

Risk factors associated with the older person

Risks factors at the individual level include:^8,14

• poor physical health or frailty
• cognitive impairment and dementia
• poor mental health, including psychiatric illness
• being in a shared living situation
• behaviour problems
• functional dependency (needing assistance with activities of daily living)
• low income or wealth
• trauma or past abuse
• ethnicity
• social isolation or loneliness
• lack of social support
• gender¹⁴

Risk factors associated with carers and people of trust

There are a number of factors to be aware of in the people who care for an older person or who are in positions of trust that increase the risk of their perpetrating abuse.

Risk factors related to the carer or care relationship include:^8,14

• caregiver burden or stress
• mental health problems
• alcohol or substance use
• financial dependency on the older person
• a history of trauma or abuse.

Relationship and community factors

Relationship risk factors include:

• a history of poor family relationships
• unrealistic expectations of caring.

Being in a shared living situation is a risk factor for abuse of older people. However, it is not clear whether spouses or adult children of older people are more likely to be the perpetrators of abuse.¹

Institutional risk factors

Within institutions, abuse is more likely to occur where:¹

• standards for healthcare, welfare services and care facilities for elder persons are low
• staff are poorly trained, poorly remunerated and overworked
• the physical environment is deficient
• policies operate in the interests of the institution rather than the residents.

The role of general practice

GPs, practice nurses and Aboriginal health workers deliver much of the medical aged care in Australia. As such they have a role to play in advocating for prevention of abuse as well as identifying and acting when an older person is involved in abuse and neglect.

Given the prevalence of abuse of older people, how should general practice and Aboriginal health services respond?

First it involves being aware of the possibility of some form of abuse happening to our older patients. A lack of understanding about abuse and neglect of older people by health professionals is one of the key barriers to abuse being identified in older patients. Other barriers include:

• the cost of implementing systems that help protect older people
• inadequate training on the signs of abuse of older people, particularly financial abuse
• limited access to standard screening and assessment tools
• inadequate organisational support to delineate pathways of care and aid the reporting of identified cases of abuse and neglect of older people.

GPs and practices therefore need to address these barriers at an individual and systems level. This might include:

• working out ways of identifying and assessing these patients (refer to ‘Identification and assessment’ below)
• when a problem is identified, having systems to manage the situation and keep the patient safe
• making the most of the opportunities in general practice where the GP has an ongoing relationship with the patient, and often the carer
• involving practice nurses and/or Aboriginal health workers when developing care plans, diabetic assessments and 75-plus health assessments, to identify possible abuse or neglect of the person being seen; it is important to ensure that everyone who does these plans and assessments understands what to do if abuse is uncovered
• looking for opportunities for ongoing education for GPs, practice nurses and Aboriginal health workers, as this has been shown to improve identification¹⁵
• helping patients who have cognitive capacity to make plans with supportive family or friends, such as appointing an enduring guardian (or equivalent in each state) and an enduring powers of attorney and writing an advance care directive. These plans can help with the care of older people, especially if they lose capacity to make their own decisions.

Identification and assessment

Identification of abuse begins with GPs being aware that the older patients we care for could be living in a situation where abuse or neglect is occurring.

It is important to be aware of the risk factors for abuse – in both the patient and their carer or other people of trust (refer to ‘Risk factors’, earlier in this chapter) – and the signs and symptoms of abuse in older patients (refer to Table 15.1).

When assessing a patient for possible abuse or neglect: 

• establish the patient’s capacity to make decisions and try only to ask about abuse when the competent patient is alone
• if the person has lost capacity, help may need to be sought from the person legally responsible for giving consent for their healthcare – if this person is the potential abuser, then seek help from the appropriate advocacy source in your state or territory (refer to Resources)
• consider using the Elder Abuse Suspicion Index (EASI) questionnaire if the patient is competent
• talk to the carer, unless this person is thought to be the perpetrator – identify someone else if possible
• be aware that the older person may be reluctant to disclose and even more reluctant to seek help because of the perceived impact on the relationship with the family
• take a detailed medical history, geriatric assessment and documentation of injuries and other issues.

Table 15.2. Elder Abuse Suspicion Index (EASI) questions 

When asking patients about possible abuse, be aware that older adults may not disclose or may be reluctant to disclose abuse because of a number of barriers, including:

• a lack of understanding about what constitutes abusive behaviour and therefore an inability to recognise when it is occurring
• fear of retaliation from the perpetrator
• feelings of guilt if the perpetrator is a child
• a desire to protect the perpetrator from negative consequences that may result if the abuse was reported.

Management

More evidence is needed to know what works to prevent or stop the abuse of older people.¹⁴ However, family mediation, as well as multidisciplinary approaches (involving counselling, legal interventions, medical care and financial controls, or restrictions on how an older person’s money can be used by those who have power of attorney) show promise.¹⁴

Regardless, the ongoing safety of the patient is paramount. This is important whether the abuse is a form of IPAV or abuse in other circumstances.

If it is decided that a patient is at risk of abuse and/or neglect, a decision needs to be made about the patient’s safety.

If the patient is assessed as at immediate risk:

• the person needs to be transferred to a hospital or aged care facility, after discussions with the patient and any supportive family
• where the patient has been assaulted or sexually abused, the police will need to be notified. 

If the patient is not assessed as at immediate risk − consider the following options:

• discuss with a carer who is not involved in the abuse and work out how to keep the older person safe and cared for without repercussions from the perpetrator (in cases where there is a non-abusive carer)
• discuss the situation with the relevant helpline in your state or territory
• discuss the case with another GP or a geriatrician
• make a referral to a geriatrician or organise a telehealth consultation
• consider respite care while the situation is being investigated and resolved
• if the patient is in an aged care facility, speak with the facility manager.

Reporting and documenting abuse of older people

Reporting abuse

A range of reporting mechanisms may be appropriate for reporting abuse, depending upon circumstances, particularly, the type of abuse, the location and the suspected abuser.

In cases of a criminal nature

If there is suspicion that a crime has occurred, or if protection is required for the victim/survivor or others, notify the police.

In cases relating to professional malpractice

The Australian Health Practitioners Regulation Agency has the power to investigate complaints relating to providers of health services, such as GPs, nurses and allied health professionals, and should be contacted in professional malpractice cases relating to residential aged care facilities. The Australian Government Department of Health Office of Aged Care Quality and Compliance addresses standards of care in residential aged care facilities and can be contacted regarding cases of known or suspected abuse occurring within a residential aged care facility.

Cases requiring guardianship intervention

If a case relates to an older adult where financial abuse is happening or the person has lost capacity to make decisions (eg due to dementia) the matter should be referred to the Public Guardian (or your state or territory equivalent) for investigation or advocacy. (Refer to Table 20.4 in Chapter 20: Violence and the law.)

Documentation

Any report or suspicion of abuse should be clearly documented, and include quotes from the patient, and others, and photographs of injuries. Documentation in residential aged care facility progress notes may be inappropriate if you know, or suspect, the abuse is being perpetrated by an employee. In this instance, progress notes should be kept off premises in the GP’s patient files.

Mr White is an 81-year-old man whose son, Gary, has moved in to live with him after his divorce some months ago.

Mr White’s GP notices that he is losing weight and has some bruising. Mr White says that he has stopped going to bowls and helping with Meals on Wheels, and he appears to be becoming depressed. This alerts the GP to the fact that something may be happening at home.

The GP uses Elder Abuse Suspicion Index (EASI) questions (refer to earlier in this chapter) and Mr White answers ‘yes’ to Question 4, which includes financial abuse. However, Mr White is reluctant to talk in much detail about what was happening with his son.

The GP calls the elder abuse helpline (refer to Resources for specific information for each state and territory) to discuss the situation and what options are available, and finds that very supportive and helps to work out a plan. After further discussions with Mr White, the GP refers him for an aged care assessment. She also refers him to the Guardianship Tribunal in her state, who interview Mr White and his son. They help direct Mr White to obtain financial management and to understand his financial rights while making very clear to Gary that he is not entitled to use Mr White’s money or to harass him about money.

Once Gary lost access to money, he moved out and Mr White, with ongoing help and support, resumed many of his previous activities and was no longer depressed.

Stephanie is an older Aboriginal woman with chronic obstructive airways disease. She lives on a Homeland, where she is cared for by her granddaughter. There is some concern about the care she is receiving, as she has needed to be brought into the main centre in town on a number of occasions. She receives good medical care in the main centre and lives with her daughter as her carer when in town.

After she is brought to the main centre again, it becomes clear that she is not receiving her medication on the Homeland. However, Stephanie does not want to remain in town, and wants to return to the Homeland to live and to receive care.

While she is in town, a family conference is arranged, including the Aboriginal health worker, to discuss the situation and to try to resolve what appears to be a lack of care and a carer’s pension being received without the care being given.

The family agreed to discuss this with the granddaughter and after the family conference there will need to be follow-up by the medical team that visits the Homeland.

Winnie, aged 69 years, is fiercely independent and lives by herself in a small country town. She has been a patient of yours for a number of years. She has severe arthritis and requires more and more help with the activities of daily living. Even with regular visits from community services, she finds it difficult to cope, but she is adamant that she doesn’t want to go to the regional hospital. Eventually she moves in with her daughter and husband and their young sons. The neighbours begin to complain about the noise. Since Winnie has moved in, there is not much space in the house and the children are fighting more often, shouting and generally playing up. Winnie’s daughter receives no help from her other sisters and is expected to cope with the increased washing, cooking and other duties without complaint.

When you see Winnie, you notice that she has marks and bruises on her arms and upper torso. These are explained away by her daughter, who says that she is becoming clumsier and keeps knocking into things. Winnie just shakes her head and says nothing, even when you speak to her in private. You are worried about pressing the issue because your clinic is the only one in town and you do not want to upset anybody.

Diagnosis: GPs need to acknowledge that abuse may be happening in this situation. The Elder Abuse Suspicion Index can help with an assessment.

Management: You may involve the home nursing service, home help, day centre, carer support groups or other local services to relieve the pressure on this family. The GPs can ring the elder abuse helpline (or equivalent) in the state.  Another alternative is to seek the help of an aged care assessment team if available. Respite care or admission to a residential aged care facility are other options, depending on what is available and what Winnie is willing to accept.

Outcome: Winnie remains in her daughter’s house with some extra aids – for example, a toilet raise, home help for bathing, respite care – which allows her daughter time out of the house, and Winnie attends the day centre once a week. It is unclear that this will alleviate the situation, so it is important to maintain a close watch on Winnie and her daughter, if possible weekly, for a time.