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The vulnerable elderly

In the third part of our new series, consultant in elderly care medicine Professor Margot Gosney offers advice on caring for older people who may be suffering abuse

In the third part of our new series, consultant in elderly care medicine Professor Margot Gosney offers advice on caring for older people who may be suffering abuse

‘Granny-battering' was first described in the UK in 1975, although much of the research in this area had previously been performed outside the UK. In 1988, a social services survey found that 5% of elderly clients were being abused and a 1990 study of the care of patients receiving respite services suggested that 45% of carers openly admitted to some form of abuse.

The first prevalence study of elder abuse in Britain was published in the BMJ in 19921. It sparked outrage and considerable dispute about the reliability of the data. The charity Action on Elder Abuse (AEA) was established in 1993 with the aim of preventing the abuse of older people.

What is adult abuse?

In March 2000, in the publication No Secrets, the Department of Health defined such abuse as: ‘A violation of an individual's human and civil rights by any other person or persons. It may be physical, verbal or psychological, it may be an act of neglect or an omission to act, or it may occur when a vulnerable person is persuaded to enter into a financial or sexual transaction, to which he or she has not consented, or cannot consent. Abuse can occur in any relationship and may result in significant harm to, or exploitation of, the person subjected to it.'2

How common is abuse?

In the UK Study of Abuse and Neglect of Older People, published in June 2007, the samples studied were representative of the general UK population aged 66 or older who were living in private households3. It found that 2.6% of these people reported that they had experienced mistreatment involving a family member, close friend or care worker in the previous year.

This would equate to a quarter of a million people living in private households in the UK being neglected or abused on an annual basis. If the definition of mistreatment is broadened to include incidents involving neighbours and acquaintances, the figure increases to 4%.

There is very little evidence about the prevalence of elder abuse in nursing and residential homes. It must be remembered that most patients within these settings are often physically frail, with marked cognitive impairment.

This means physical injuries may be poorly reported and, without input from healthcare professionals, family and friends, many older people may suffer abuse that is unrecognised and therefore under-reported. Coincidental falls, the use of bed restraints and high levels of medication make it difficult to detect and quantify.

What type of abuse occurs?

41240661Physical abuse usually takes the form of slapping, shaking or inflicting physical damage. Sexual abuse includes any sexual act to which a person has not agreed. Financial abuse involves stealing somebody's money, or denying them access to their money or possessions. Older individuals may also feel pressure in connection with wills, property, inheritance or financial transactions. The misuse or misappropriation of property, possessions or benefits are also defined as financial abuse.

Psychological abuse is more difficult to define. Any threat of harm, abandonment, humiliation, intimidation or verbal abuse that results in psychological distress is a form of abuse. There is evidence that psychological abuse is probably the most common type experienced by older people, but is taken least seriously by healthcare professionals. It could be argued that leaving an elderly person in a revealing gown or nightdress, in the absence of underwear in a public environment, is the commonest form of psychological abuse seen within many healthcare settings. Shouting at an older person is often considered to be acceptable because of the likelihood of deafness – but is neither helpful nor appropriate and may cause fear and distress.

Neglect by ignoring medical or care needs is a further example of abuse and includes depriving people of their medication (particularly pain relief), leaving people without easy access to food or drink, and failure to deal with issues of continence. Discriminatory abuse includes racist, sexist or other comments based on a person's disability.

Who is abused?

Women are more likely to say that they have experienced mistreatment than men. Men aged 85 and above are more likely to experience financial abuse than those in younger age groups, and women in this age group are more likely to have been neglected.

Mistreatment varies with socioeconomic position, with those living in rented housing having a higher prevalence than those who are in owner-occupied accommodation. Abuse also varies by marital status, with almost 10% of those who are separated or divorced having experienced mistreatment, compared with 1.4% of those who are widowed. Those living alone are more likely to experience financial abuse than those who live with others.

Who are the perpetrators?

In the 2007 study, which excluded stranger abuse, 51% of the mistreatment involved a partner or a spouse, 49% another family member, 13% a care worker and 5% a close friend. When abuse is interpersonal – physical, psychological or sexual – perpetrators are four times more likely to be male than female. The perpetrators who carry out financial abuse are more likely to be younger than those carrying out interpersonal abuse.

More than half of all perpetrators live in the respondent's household at the time of abuse. It must be remembered that perpetrators could be any individuals who come into contact with older people. They can be healthcare or social care professionals, volunteers, friends and neighbours, or someone well known to the vulnerable adult.

Is abuse reported?

In the 2007 UK study, 70% of older people said that they had reported the incident or sought help, although only in 30% of cases was this help sought from a health professional or social worker.

But this study fails to address abuse that occurs in residential or nursing care, or in those who are not able to convey the abuse that has occurred because of cognitive decline or disability.

The Commission for Social Care Inspection (CSCI) found that in 20% of care services, nobody interviewed could remember receiving or understanding information about what to do if they had concerns about abuse.

Risk factors for abuse

In one of the earlier studies of abuse of patients in the community who were subsequently admitted for respite, two characteristics of carers were associated with abuse: poor long-term relationships and a history of alcohol misuse. There is evidence that any carer who has other significant dependents is more at risk of being an abuser. A history of mental ill health, substance misuse, violence or abuse, either as a victim or as a perpetrator, increases the chances that an individual will abuse an older adult.

When any individual is dependent on a vulnerable adult for financial support or accommodation, abuse is more common – for example, the son or daughter who is living with an elderly parent in the knowledge that if their elderly parent goes into a nursing home, they will lose not only financial benefit, but also the benefit of living under the parent's roof. Under these circumstances, healthcare professionals must be vigilant to ensure carers do not insist that a vulnerable adult remains in the community, when nursing home care might be more appropriate.

Many carers are faced with the loss of one parent, or indeed of a spouse or partner, just prior to taking on the role of carer. These people are at increased risk of abusing, as are those living in inadequate living conditions.

Within the nursing and residential home settings, a number of factors have been identified as potentially increasing the abuse of older adults. Poor management and inadequate communication between staff and managers are associated with abuse.

Lack of support for staff working in an authoritarian atmosphere may also put residents at increased risk. Lack of training, particularly concerning privacy and dignity, as well as basic nursing care, may result in abuse as a definite activity, or in neglect because of staff ‘knowing no better'. Any institution where there is poor recording of complaints and little contact with the outside world may result in abuse being undetected for long periods of time.

It is known that one of the major identified forms of abuse that occurs in the nursing home setting is the overadministration of medication to ensure older residents are compliant and quiet. This may result in a sleepy older person, who has poor fluid and food intake, which may in turn predispose to infections and a higher incidence of falls.

Reporting elder abuse

All employees have a duty to report any suspicions of abuse, and individual organisations should operate a whistleblowing policy that protects people who report their concerns. Most social services departments have a lead for safeguarding adults who should be the first point of contact when abuse is suspected. These individuals will work with others to ensure that all reports are fully investigated, that strategy meetings are held and that individuals are safeguarded where abuse has occurred or the potential for abuse exists.

The quickest way to find your local safeguarding adults co-ordinator is to search the website of the local social services for a link entitled ‘Safeguarding Adults', where emergency numbers are usually provided.

Who forms the multi-agency safeguarding board?

Social services departments lead all multi-agency investigations and are responsible for documentation, communication with other professionals, leading strategy meetings and for the future support of the individual who may have been abused. They work very closely with the police, who will be involved not only if criminal charges are to be brought, but also in the investigation of suspected abuse.

The CSCI works closely with the safeguarding board and is responsible for inspections of nursing and residential homes within a particular geographical area. Health is represented usually by both primary and secondary care trusts and a close working relationship is essential to ensure patients move from one environment to another in a seamless fashion, and that abuse that has occurred within the community can be reported in secondary care and vice versa. The private and voluntary organisations are usually well represented, particularly since many of them will have contact with older people who may not be known to both health and social care services.

Organisations bringing together all nursing and residential homes in an area will provide insight into reporting mechanisms and their involvement will also ensure that there is consistent training across all organisations.

Professor Margot Gosney is director of clinical health sciences and consultant in elderly care medicine at the University of Reading

This is an extract from Managing Older People in Primary Care, a practical guide for clinicians involved in the day-to-day care of older people in the community. With most chapters co-authored by a specialist and a GP, it provides an indispensable resource, including tips on differential diagnosis and summaries of the existing evidence-base, and guidelines on treatment. For more information and to order your copy at a 20% discount visit www.oup.com/uk/isbn9780199546589 and quote the promotion code PULSE.

key points Vulnerable elderly

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