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RACGP aged care clinical guide (Silver Book)

Silver Book - Part B

Abuse of older people

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Last revised: 16 Jan 2020

  • The abuse of older people can involve financial, emotional, physical and sexual abuse, and neglect.
  • Abuse of older people occurs in families, with paid carers and in residential aged care facilities (RACFs).
  • Abuse is a significant risk to the older person’s health and wellbeing.
  • There are barriers that may prevent an older person from disclosing abuse.
  • Talking to older people about the possibility of abuse should only be done with the patient alone.
  • Care for the older person’s safety and wellbeing is paramount.

The World Health Organization (WHO) defines the abuse of older people as:1

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 financial, physical, psychological and sexual. It can also be the result of intentional or unintentional   neglect.

There are a number of recognised forms of abuse, which include financial, emotional, physical, sexual and neglect. This may be occurring in the person’s home, when they are staying with family members, or in a residential aged care facility (RACF). The perpetrators may be sons or daughters, other family members, paid carers, other residents in the RACF, and potentially anyone with whom they have contact.

The term ‘abuse of older people’ has been chosen over ‘elder abuse’ in the Silver Book in deference to Aboriginal and Torres Strait Islander peoples for whom the title of ‘elder’ has such cultural significance.

The WHO estimates that 15.7% of people aged ≥60 years are subjected to abuse. These prevalence rates are likely to be underestimated as many cases of abuse of older people are not reported, and often occur behind closed doors. Globally, the numbers of people affected are predicted to increase as many countries are experiencing rapidly ageing populations.1 The WHO estimates that the rate of abuse of older people in middle-income and high-income countries such as Australia is between 2% and 14%.

Hence, significant numbers of people will be affected by abuse of older people, and this has the potential to have a significant impact on their health and wellbeing.

Australian data estimate that there were 3.8 million older Australians in 2017,2,3 which, based on the 2–14% figure aforementioned, indicates that between 76,000 and 532,000 older Australians experience some form of abuse.

Given this significant prevalence, all general practices and general practitioners (GPs) who see older patients will be potentially seeing older people who are experiencing abuse.

All medical practitioners, healthcare professionals, family members and RACF staff need to be able to recognise and identify older people who may be experiencing abuse. They should be aware that the risk of abuse of older people increases as people become frailer, more dependent on care and develop dementia.4 Some of the factors that contribute to the abuse of older people are shown in Table 1.

Factors that contribute to the abuse of older people

Table 1.

Factors that contribute to the abuse of older people5

There is also an additional risk if there was ongoing family violence prior, where, in some cases, the perpetrator becomes the victim.

Assessment

The first step of the assessment of abuse of older people is to be aware of the risk that this is happening. It is important to look for signs such as:

  • depression
  • not able to pay for things (eg medication, other personal needs)
  • bruising
  • unexplained falls
  • weight loss
  • bed sores
  • decreasing levels of hygiene
  • changes in the patient’s demeanour.

Further signs and symptoms of the abuse of older people are shown in Table 2.

Table 2.

Table 2.

Signs and symptoms of the abuse of older people

Be aware of the environment in which the conversation is had with the patient; make sure the conversation cannot be heard by anyone else, and reassure the patient about confidentiality. Tools such as the Elder Abuse Suspicion Index (EASI), which has been validated for older people without dementia, can assist this process.

A safety plan needs to be implemented if the GP establishes that there is a possibility that the older patient is experiencing abuse.

Dementia

Older people with dementia who GPs believe are being abused are much more difficult to identify as the signs of abuse listed above may also be associated with dementia per se (refer to Part A. Dementia). However, it is important to note that abuse is common in people living with dementia.6 Abuse may be detected through a full history and physical examination, preferably in the presence of someone who is unlikely to be the perpetrator.7

Culturally and linguistically diverse populations

Patients from a culturally and linguistically diverse (CALD) population group may benefit from an ethno-specific worker who establishes a relationship with them and their family, and undertakes dementia education with the group (refer to Part B. Multiculturalism in aged care ).

Aboriginal and Torres Strait Islander peoples

Aboriginal and Torres Strait Islander peoples will benefit from discussion and support involving an Aboriginal health worker, who can provide a culturally safe intervention (refer to Part B. Older Aboriginal and Torres Strait Islander peoples).

Barriers

Be aware of some of the barriers to disclosure of abuse of older people:

  • Some patients will not identify what is happening to them as abuse.
  • Some will be very afraid of the perpetrator and what might happen if they talk about the abuse.
  • Some will be too ashamed to talk about it and consider it their own fault.
  • Some will make excuses for the carer.
  • Some patients will have dementia and be unable to tell their GPs what is happening.

Be aware of some of the barriers to asking older people about abuse:

  • It is difficult to believe that older frail people are being abused by people who are their carers.
  • It is hard or near impossible to believe that this could be happening in this family or RACF.
  • There is no time to ask.
  • Uncertainty about what to do if abuse of older people is discovered.

If there is a possibility that abuse of an older person may be happening, plans need to be made around how to manage the situation and the patient’s safety. The patient’s wishes need to be taken into consideration, but there may be times when a GP may consider they are at significant risk and not safe in their current situation.

Not at immediate risk

If the patient is not at immediate risk, consider the following:

  • 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.
  • Ring the state or territory telephone line or other service to discuss the case in confidence.
  • Discuss the case with another GP in the practice or local geriatrician.
  • Make a referral to a geriatrician to assess the patient (if the patient can be seen soon) or organise a teleconference.
  • Respite care may provide the patient with some safety while the situation is being resolved.
  • Talk to the nurse unit manager at the RACF, provided this person is not the perpetrator and will assist the patient.

Immediate risk

If the patient is at immediate risk, consider the following:

  • Make an immediate referral to the local hospital after discussing the circumstances in private with the admitting officer.
  • If the patient has physical injuries or there is a suggestion of sexual assault or physical abuse, this should be reported to the police.
  • If the problem relates to the RACF, then the incident should be reported to the Department of Health.
  • Patients who need guardianship due to dementia or abuse from their current carer can be referred to the guardianship board in your state or territory – this can be done urgently where necessary.
  • The issues with the perpetrator also need to be addressed. Support for the perpetrator might also be discussed.

Instigating systems that will help to keep older people safe will involve the following:8

  • Working with carers and families to prevent, as far as possible, ‘carer stress’ that can contribute to the abuse of older people. This involves discussing carer stress at an early stage of care, and planning services to support the carer; however, ‘carer stress’ is never an excuse for abuse.
  • Referring to organisations (eg Dementia Australia, Dementia Behaviour Management Advisory Service) that can work with family and other carers to support them, and provide services that prevent carers from being overwhelmed by the care needed by the older person. The aged care assessment team (ACAT) uses the Modified Caregiver Strain Index (MCSI).9
  • RReferring professional carers to training organisations (eg Dementia Australia) to assist in the recognition of signs of abuse and familiarity with a safe reporting system provided by their employers or the Elder Abuse Helpline.
  • Addressing the issue in RACFs, and developing systems to prevent it happening and recognising it if does occur. Additionally, addressing cases of abuse of older people if they are reported so other residents are not affected. GPs can help in this process by being an advocate for patients and asking the nurse unit manager about processes in the RACF.

None of these measures will prevent all abuse of older people, and there will be more recommendations from the Royal Commission into Aged Care Quality and Safety once it concludes.

The GP is able to be an ‘outsider’ who knows the patient, and needs to be an advocate for their care and respond to any possible abuse.

Abuse of older people contacts in each state and territory:
  • Australian Capital Territory – ACT Disability, Aged and Carer Advocacy Service: 02 6242 5060
  • New South Wales – Elder Abuse Helpline: 1800 628 221
  • Northern Territory – Executive Office of Adult Guardianship:
    • Darwin: 08 8922 7343
    • Alice Springs: 08 8951 6028
    • Office of Public Guardian: 08 8951 6741
  • Queensland – Elder Abuse Prevention Unit: 1300 651 192
  • South Australia – Office of the Public Guardian: 08 8342 8200
  • Tasmania – Office of Public Guardian: 03 6165 3444
  • Western Australia – Office of the Public Guardian: 1300 858 455
  • Victoria – Seniors Rights Victoria: 1300 368 821
  • Aged care and aged care rights
  • National Institute on Aging
  1. World Health Organization. Ageing and life-course: Elder abuse. Geneva: WHO, 2017. [Accessed 3 June 2019].
  2. Australian Institute of Health and Welfare. Australia’s welfare 2017: Ageing and aged care. Canberra: AHIW: 2018. [Accessed 3 June 2019].
  3. Australian Institute of Health and Welfare. Australia's welfare 2017. Canberra: AIHW, 2017. [Accessed 3 June 2019].
  4. The Royal Australian College of General Practitioners. Abuse and violence – Working with our patients in general practice. Melbourne: RACGP, 2014. [Accessed 3 June 2019].
  5. Pillemer K, Burnes D, Riffin C, Lachs MS. Elder abuse: Global situation, risk factors, and prevention strategies. Gerontologist 2016;56:S194–205. [Accessed 3 June 2019].
  6. Dong X, Chen R, Simon MA. Abuse and dementia: A review of the research and health policy. Health Affairs 2013;33(4):642–49. [Accessed 3 June 2019].
  7. Hoover RM, Polson M. Detecting elder abuse and neglect: Assessment and intervention. Am Fam Physician 2014;89(6):453–60. [Accessed 3 June 2019].
  8. Australian Law Reform Commission. Elder abuse – A national legal response. Sydney: ALRC, 2017. [Accessed 3 June 2019].
  9. Thornton M, Travis SS. Analysis of the reliability of the modified caregiver strain index. J Gerontol B Psychol Sci Soc Sci 2003;58(2):S127–32. [Accessed 3 June 2019].