Abuse and violence - Working with our patients in general practice


The White Book
Section 10.1 Elder abuse
☰ Table of contents


Key messages

  • Abuse may be physical, emotional, sexual or financial and may include neglect. It can occur in an aged care facility or in the community11
  • Risk factors for elder abuse can be related to the individual, the perpetrator, relationships and the wider environment248, 249
 

Recommendations

  • Elder abuse needs to be considered by any health practitioner seeing elderly patients, as they have a pivotal role in the recognition, assessment, understanding and management of elder abuse and neglect250 Practice point
  • If confronted with elder abuse, establish the patient’s capacity to make decisions. Help may need to be sought from the person legally responsible for giving consent for their healthcare. If this person is the abuser, then seek help from the appropriate advocacy source in your state or territory251Practice point

 

Introduction


Elder abuse is defined as any type of abuse – physical, emotional, sexual, economic – or neglect of people aged 65 years or over, either in an residential aged care facility (RACF), in private care, or living independently. It 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.11 Elder abuse occurs in all cultural and socioeconomic strata whenever there is an imbalance of power252 and is linked to increased mortality and disability.253

Abuse may occur to an elderly person being cared for by family or other community carers, or in an RACF and hospital when the frailty of elderly residents renders them unable to defend themselves. An abuser may be a family member or carer, and 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.

Elder abuse may occur for many reasons, covering individual, relationship, community and sociocultural causative factors.252 For example, caring for a family member means there may be a change in role where the carer becomes the ‘parent’ and the ‘parent’ becomes the ’child’. This increasing dependency can be frustrating and act as a catalyst for abusive behaviour by the carer, particularly if the carer is insufficiently supported.

The ongoing safety of the patient is paramount. Safety may only be achieved by transferring the patient from home or from the RACF. For elderly people the fear of retribution is strong and may be contributing to their unwillingness to disclose.11

 

Prevalence


There are no recent national statistics in relation to elder abuse254 and few worldwide. A NSW study of clients referred to an Aged Care Assessment Service showed that 4.6% of older people living in the community and referred to the Aged Care Assessment Service had experienced elder abuse.255 A study of four Aged Care Assessment Teams in QLD, WA and NSW showed a prevalence rate of 2.3%256 and a study in a large regional aged care service in NSW found 5.4% of clients referred had also experienced elder abuse.257 In studies in the United States (where participants aged 60 and over are included), the prevalence of elder abuse ranged from 11.4% to 14.1%.248,258 Apart from the age of those participants included in the studies, discrepancies in prevalence rates may be due to issues of definition as some types of elder abuse were not included.254

In addition, there may be five unreported instances of abuse to every one reported.259 The real prevalence of elder abuse is obscured due to a number of factors, including fear of retribution when reporting a complaint. The ageing of Australia’s population and the increasing numbers of adults with dementia contribute to the anticipated growth in the prevalence of elder abuse.260

 

The role of GPs


The Australian Medical Association (AMA) stipulates in its position statement on the care of older people that GPs have a ‘pivotal role in the recognition, assessment, understanding and management of elder abuse and neglect’.250

GPs are often the first independent professional to see an elderly victim of abuse. There are a number of reasons why medical practitioners may not have been more involved in managing cases of abuse. These include lack of awareness, insufficient knowledge regarding identification or follow-up of a potential case, ethical issues, time constraints, and the victim’s potential reluctance to report the abuse.11

 

Identification


Understanding the risk factors for people who abuse vulnerable elders can provide information for intervention and preventive strategies.260

Risk factors can include:248,249

  • individual
    • cognitive impairment
    • behavioural problems
    • psychiatric illness or psychological problems
    • functional dependency
    • poor physical health or frailty
    • low income or wealth
    • trauma or past abuse
    • ethnicity
  • perpetrator
    • caregiver burden or stress
    • psychiatric illness or psychological problems
  • relationship
    • problems within the family
    • relationship conflicts
  • environment
    • low social support
    • living with others (except for financial abuse).

 

Types of presentations in general practice


A US study found that community-dwelling middle-aged and older women who reported physical abuse in the preceding year, verbal abuse or both types of abuse had significantly higher adjusted mortality risk than non-abused peers.261

A predisposing factor to elder abuse is dependency caused by physical impairment, dementia, mental illness, stroke, sensory impairment, or intellectual impairment.252 This risk factor occurs regardless of whether the older person is being cared for in the home or in an RACF. However, as the majority of RACF residents have some form of dependency, such as physical or cognitive impairment, the GP and RACF staff should be alert to the possible occurrence of elder abuse.248 Refer to Table 15 for a list of possible signs and symptoms of elder abuse.

Table 15. Possible signs and symptoms of elder abuse262

General behaviour

  • Being 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
  • Avoiding eye contact or eyes darting continuously
  • Contradictory statements not from mental confusion
  • Reluctance to talk openly

Physical abuse

  • A history of physical abuse, accidents or injuries
  • Injuries such as skin trauma, including bruising, skin tears, burns, welts, bed sores, ulcers or 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

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

  • 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
  • Unusual behaviour or confusion not associated with illness

Economic abuse

  • History of fraudulent behaviour or stealing perpetrated on the patient
  • Lack of money to purchase medication or food
  • Lack of money to purchase personal items
  • Defaulting on payment of rent or RACF fees
  • Stripping of assets from the family home or use of assets for free

Neglect

  • A history of 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

If the possibility of abuse is suspected or concern is raised, you can use the consultation time to observe the emotional reactions and body language of the older person and the suspected abuser. Also, you can observe face-to-face interactions between the two. If the patient is in an RACF, remember that an abuser may be another resident (sometimes with dementia), a staff member (including volunteers), visitors or family members.

 

Management


If the patient has the capacity to give a history, it should be taken without others present. If this history differs from that given by carers or other family members, suspicions should be raised.251 Ask the patient direct questions (refer to Tool 6. Elder Abuse Suspicion Index), and if suspicion of abuse is confirmed, you can request permission from the patient to report the information to the appropriate parties (Table 16). However, although there is no legal compulsion requiring GPs to report elder abuse, any abuse affects the health and wellbeing of the patient and therefore the GP needs to have a response that ensures safety for the patient (refer to Chapter 13 ).


Management of sexual or physical assault

If you are given permission by the patient, or you are satisfied that there are grounds to believe that the patient has been abused sexually or physically (eg the patient’s guardian has told you of the abuse) you may want to notify the police. Once it is established by the police that abuse has occurred, they will conduct any further notification or questioning.

In criminal cases you should document all injuries and consider photographing injuries before initiating treatment. You will need to gain consent from the patient to photograph injuries. In the case of sexual assault, evidence may need to be collected by forensic examination. Refer to Chapter 9 and resources for details about consulting forensic specialists or referring patients to them.

Table 16. Reporting and documenting

Reporting elder abuse – there is a range of reporting mechanisms that may be appropriate, depending upon the specific circumstances – particularly the type of abuse, the location and the suspected abuser

  • Cases of a criminal nature – if there is suspicion that a crime has occurred or if protection is required for the survivor or others, the police should be notified
  • Cases relating to professional malpractice – the Australian Health Practitioners Regulation Agency (AHPRA) 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 the RACF. The Australian Government Department of Health Office of Aged Care Quality and Compliance addresses standards of care in RACFs and can be contacted regarding cases of known or suspected abuse occurring within an RACF
  • Cases requiring guardianship intervention – if the case relates to an older adult who has lost capacity to make decisions (for example, due to dementia) the matter should be referred to the Public Guardian (or your state equivalent) for investigation or advocacy. Refer to Table 19 in Chapter 13, and Resources in the PDF version)

Documentation – any report or suspicion of abuse should be clearly documented, including quotes from the patient, and others, and photographs of injuries. Documentation in RACF progress notes may be inappropriate if the doctor knows of, or suspects, the abuse is being perpetrated by an RACF employee. In this instance, progress notes should be kept off premises in the GP’s patient files

 

A rural perspective


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.

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. 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.

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 with weekly house calls.

  1. World Health Organization. A global response to elder abuse and neglect: building primary health care capacity to deal with the problem worldwide: main report. Geneva: WHO, 2008. 
  2. Post L, Page C, Conner T, Prokhorov A, Fang Y, Biroscak BJ. Elder abuse in long-term care: types, patterns, and risk factors. Res Aging 2010;32:323–48. 
  3. Johannesen M, LoGiudice D. Elder abuse: a systematic review of risk factors in community-dwelling elders. Age Ageing 2013;42:292–8. 
  4. Australian Medical Association. AMA Position Statement on Care of Older People 1998 – amended 2000 and 2011, 2011. 
  5. Glasgow K, Fanslow J. Family Violence Intervention Guidelines: Elder abuse and neglect. Wellington: Ministry of Health, 2006.  
  6. World Health Organization. Elder maltreatment fact sheet. Geneva: WHO, 2011. 
  7. Schofield MJ, Powers JR, Loxton D. Mortality and disability outcomes of self-reported elder abuse: a 12-year prospective investigation. J Am Geriatr Soc 2013;61:679–85. 
  8. Kurrle S, Naughtin G. An overview of elder abuse and neglect in Australia. J Elder Abuse Negl 2008;20:108–25. 
  9. Kurrle SE, Sadler PM, Cameron ID. Elder abuse – an Australian case series. Med J Aust 1991;155:150–3. 
  10. Kurrle SE, Sadler PM, Lockwood K, Cameron I. Elder abuse: prevalence, intervention and outcomes in patients referred to four aged care assessment teams. Med J Aust 1997;166:119.
  11. Livermore P, Bunt R, Biscan K. Elder Abuse among Clients and Carers Referred to the Central Coast ACAT: a Descriptive Analysis. Australas J Ageing 2001;20:41–7. 
  12. Acierno R, Hernandez MA, Amstadter AB, et al. Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: the National Elder Mistreatment Study. Am J Public Health 2010;100:292–7. 
  13. National Centre on Elder Abuse. Fact Sheet: Elder Abuse Prevalence and Incidence. Washington: National Centre on Elder Abuse, 2005. 
  14. Elder Abuse Prevention Project. Strengthening Victoria’s Response to Elder Abuse. Melbourne: State Government of Victoria, Department for Victorian Communities, 2005. 
  15. The Senate Committee of Inquiry. Quality and equity in aged care report. Canberra: Commonwealth Government of Australia, 2005. 
  16. Yaffe MJ, Tazkarji B. Understanding elder abuse in family practice. Can Fam Physician 2012;58:1336–40. 
  17. Cupitt M. Identifying and addressing the issues of elder abuse: a rural perspective. J Elder Abuse Negl 1997;8:21–30.