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Which problems can be helped by a hand surgeon?

Taking action in

a suspected case of elder abuse

Case

history

Mrs Smith is 85, has angina and lives in a purpose-built granny flat attached to her son's house, where she is cared for mainly by her daughter-in-law. When you visit her because of a chest infection you notice several unexplained bruises on her arms and back. Her daughter-in-law says Mrs Smith is a bit unsteady and tends to fall. Dr Melanie Wynne-Jones discusses.

What are the possible medical explanations for the bruises?

Mrs Smith has angina so is presumably on aspirin which can predispose to easy bruising. If she is on warfarin for any reason, you will need to check compliance, possible drug interaction and when she last had an INR. She will also need a full blood count and, if she is genuinely falling, a full 'falls' work-up.

Is Mrs Smith likely to say anything if she is being abused?

Elder abuse often goes undetected because:

·The signs, or their significance, are not recognised

·Plausible explanations are given by the abused who are frightened to speak out or incapacitated by speech/cognitive impairment

·Plausible explanations are given by the abuser who ensures the abused person cannot speak to other people alone

Older people who are abused may still love the person who is abusing them, despite their actions, or be dependent on them emotionally, financially, or for a home. Abuse may be the price they are willing to pay to avoid being left alone or going into care.

The Commons Health Committee has estimated that as many as half a million elderly people are the victims of abuse1.

Who abuses the elderly?

Potentially anyone who spends time alone with

an elderly person:

·Spouses In the case of either sex, elder abuse may be a continuation of a long-standing abusive relationship. It may start in older life because one of them is developing dementia/other illness or because the abused has become more dependent.

·Other family members who resent the abused person for emotional, workload, financial or interpersonal reasons.

·Neighbours or volunteers.

·Carers who visit the elderly in their homes; and carers in residential/nursing homes ­ particularly if poorly run with inadequate training, supervision and support.

·Health professionals.

An analysis of 1,421 calls received by Elder Abuse Response between 1997 and 1999 revealed that a quarter of calls referred to abuse in hospitals, nursing and residential settings, and named paid workers2.

Risk factors include:

·Social isolation

·Poor relationship between carer and abused

·A history of previous abuse of violence within the family

·Dependence by the carer on the older person ­ financial, emotional, accommodation

·Mental health problems, personality disorder or substance abuse in the carer

What might lead you to suspect elder abuse?

Action on Elder Abuse (AEA)3 defines it as: '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,'

There are six main types1:

·Physical ­ deliberate rough handling, enforced restraint, assault, or administering excessive/unprescribed medication or noxious substances

·Psychological/emotional ­ shouting, bullying, ignoring, blaming or humiliating

·Financial ­ stealing property or money, forcing the person to change their will

·Sexual ­ any unwanted sexual activity

·Neglect ­ failing to provide adequate fluids, food, medicines, warmth, clean clothing and other necessities

·Discriminatory ­ racist and so on

What is the GP's role in detection?

The possibility of elder abuse should always be borne in mind. The AEA website includes a detailed and alarming list of possible indicators/ red flags that GPs may encounter.

Information from third parties such as relatives, neighbours, other carers or health professionals should also be taken seriously. The practice should have a strategy for sharing information and taking action.

Research by the Community and District Nursing Association suggests 88 per cent of district and community nurses in the UK have encountered elder abuse during the course of their work4.

The new GP contract requires GPs to keep a register of carers who can be specifically asked about how they are coping with their role; signs of stress should prompt consideration of whether their charge is at risk.

The practice should also consider training needs and have a policy for tackling suspected/ alleged elder abuse by health professionals.

Taking action where abuse is supected

Abuse may be uncovered during an acute

illness or injury, but the situation is not always as clear-cut.

Talking to the older person alone where you have suspicions may be hard to achieve. It is also a difficult subject to raise sensitively, and the person may deny it anyway.

Depending on the harm done, the individual circumstances and the level of ongoing risk, options for investigating or dealing with suspected abuse include:

·Contacting social services with concerns about an individual. Social services may then be able to increase support in the home to relieve practical or financial strain for the carer, or offer residential care. If serious abuse has occurred they can take over legal responsibility for protecting the abused person, and contact the police if necessary.

·Contacting social services with concerns about a registered residential/nursing

home. The establishment may need to be closed down.

·Reporting abuse by care workers or health professionals.

·Referring the patient to secondary care for physical or psychiatric assessment and care.

·Providing care for the abuser (if registered with the practice) when the abuse means the patient's needs are not being met.

You may need to talk to your trainer, your medical defence organisation or even Action on Elder Abuse5 before taking action.

Melanie Wynne-Jones is a GP in Marple, Cheshire

Key points

·Elder abuse may affect as many as half a million people in this country

·Awareness of risk factors and warning signs may identify those at risk

·Anyone, including health professionals, may be abusers

·GPs must take action if they suspect abuse

·Practices should keep a register of carers and be aware of their needs

References

1. Elder Abuse Commons Health Comittee Report (2004) www.parliament.uk/parliamentary_committees/health_committee

2. Action of elder abuse: listening is not enough (2000) www.elderabuse.org.uk/documents/reportsetc/Listen.htm

3. Action on Elder Abuse www.elderabuse.org.uk/Mainpages/Questions.htm

4. Community and District Nursing Association ­ Campaign: Tackling Elder Abuse. www.cdna.tvu.ac.uk/ElderAbuse/Elderabuseindex.asp

5. Action on Elder Abuse Response Helpline provides information and emotional support for anyone who is concerned about an older person being abused and is totally confidential. Freephone: 0808 808 8141 www.elderabuse.org.uk

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