Rural and remote communities present another set of challenges associated with the lack of RACFs and access to other services.263 In some rural communities people living in an RACF will be some distance from their families and will be more isolated. There is also the understated issue of maintaining confidentiality within small community groups. Below is a case study from a rural area that illustrates some of the issues.
Case study: Winnie
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 make house calls to 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.
GPs need to acknowledge that abuse may be happening in this situation. The Elder Abuse Suspicion Index can help with an assessment.
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. Another alternative is to seek the help of an aged care assessment team if available. Respite care or admission to an RACF are other options, depending on what is available.
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 with weekly house calls.