DELHI PSYCHIATRY JOURNAL Vol. 11 No.2 OCTOBER Elder Abuse

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1 Review Article Elder Abuse M.S. Bhatia, Shruti Srivastava, Shwetank Bansal Department of Psychiatry, UCMS & GTB Hospital, Dilshad Garden, Delhi All the world s a stage, and all the men and women merely players. They have their exits and their entrances, And one man in his time plays many parts. His acts being seven ages As You Like It by William Shakespeare Last scene of all, that ends this strange eventful history, is second childishness and mere oblivion. Sans teeth, sans eyes, sans taste, sans everything. -Jacques, in Our elders are at risk, and we are the perpetrators In the above lines, Shakespeare refers to senility as Second Childishness underlining the fact that our elders need to be cared for as meticulously, as we care for our children. Sadly, this is not the case, and the incidence of reported events of elder abuse is on the rise, so much so that the United Nations has had to sit up and take notice. (The U.N. has designated June 15 as World Elder Abuse Awareness Day) The Problem Elder Abuse has been defined 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. That the Government of India has had to pass a legislation regarding this (Maintenance and Welfare of Parents and Senior Citizens Act, 2007), serves testimony to the degeneration of the respect and reverence attached to our elders, that was once second nature to all of us in India. 150 Where is it Happening? Whereas in the Western world, where elderly living in old age institutions, or nursing homes bear the brunt of abuse, in our country, they have fallen prey to their own family in what were once considered the safe confines of home. According to a rough estimate, nearly 40% of senior citizens living with their families are reportedly facing abuse of one kind or another, but only 1 in 6 cases actually comes to light. A general population study conducted in London, in March this year, reported that as many as 6% old people admitted having faced significant abuse in the past one month. 1

2 OCTOBER 2008 DELHI PSYCHIATRY JOURNAL Vol. 11 No.2 Types of Elder Abuse Abuse of elders takes many different forms, some involving intimidation or threats against the elderly, some involving neglect, and others involving financial chicanery. Patterns of abusehave been identified and related to the psychopathology of the abuser(30%), dependency of the older person and carer stress(25%), domestic violence (19%), carer abuse(18%) and financial dependency(8%). 2 The most common forms of elder abuse are defined below. Physical abuse Physical elder abuse is non-accidental use of force against an elderly person that results in physical pain, injury, or impairment. Such abuse includes not only physical assaults such as hitting or shoving but the inappropriate use of drugs, restraints, or confinement. Emotional abuse In emotional or psychological senior abuse, people speak to or treat elderly persons in ways that cause emotional pain or distress. Verbal forms of emotional elder abuse include intimidation through yelling or threats humiliation and ridicule habitual blaming or scapegoating Nonverbal psychological elder abuse can take the form of ignoring the elderly person isolating an elder from friends or activities terrorizing or menacing the elderly person Sexual abuse Sexual elder abuse is contact with an elderly person without the elder s consent. Such contact can involve physical sex acts, but activities such as showing an elderly person pornographic material, forcing the person to watch sex acts, or forcing the elder to undress are also considered sexual elder abuse. Neglect or abandonment by caregivers Elder neglect, failure to fulfill a caretaking obligation, constitutes more than half of all reported cases of elder abuse. It can be active (intentional) or passive (unintentional, based on factors such as ignorance or denial that an elderly charge needs as much care as he or she does). Financial exploitation This involves unauthorized use of an elderly person s funds or property, either by a caregiver or an outside scam artist. An unscrupulous caregiver might misuse an elder s personal cheques, credit cards, accounts or insurance claims steal cash, income cheques, household goods, or property documents forge the elder s signature engage in identity theft Typical rackets that target elders include Announcements of a prize that the elderly person has won but must pay money to claim Phony charities Investment fraud Healthcare fraud and abuse Carried out by unethical doctors, nurses, hospital personnel, and other professional care providers, examples of healthcare fraud and abuse regarding elders include Not providing healthcare, but charging for it Overcharging or double-billing for medical care or services Getting kickbacks for referrals to other providers or for prescribing certain drugs Overmedicating or undermedicating Recommending fraudulent remedies for illnesses or other medical conditions Medicaid fraud Who is at Risk? The main risk factors for elder abuse are generally considered to be : 1. Social isolation of the abused person and/or the family 2. Frailty of the victim, functional disability and cognitive impairment 3. Pathology of the abuser, such as alcohol or other substance abuse, cognitive impairment and mental health problems 4. Caregiver stress or anger 5. Dependence of the victim on the abuser (e.g. the caregiver is the abuser) or dependence of the abuser on the victim (e.g. an adult child with financial dependence on the parent is the abuser). 151

3 The risk factors listed above are gender-neutral How to Detect Elder Abuse? At first, you might not recognize or take seriously signs of elder abuse. They may appear to be symptoms of dementia or signs of the elderly person s frailty or caregivers may explain them to you that way. In fact, many of the signs and symptoms of elder abuse do overlap with symptoms of mental deterioration, but that doesn t mean you should dismiss them on the caregiver s say-so. General signs of abuse The following are warning signs of some kind of elder abuse: Frequent arguments or tension between the caregiver and the elderly person Changes in personality or behavior in the elder If you suspect elderly abuse, but aren t sure, look for clusters of the following physical and behavioral signs. Signs and symptoms of specific types of abuse Physical abuse Unexplained signs of injury such as bruises, welts, or scars, especially if they appear symmetrically on two sides of the body Broken bones, sprains, or dislocations Report of drug overdose or apparent failure to take medication regularly (a prescription has more remaining than it should) Broken eyeglasses or frames Signs of being restrained, such as rope marks on wrists Caregiver s refusal to allow you to see the elder alone Emotional abuse In addition to the general signs above, indications of emotional elder abuse 152 include Threatening, belittling, or controlling caregiver behavior that you witness Behavior from the elder that mimics dementia, such as rocking, sucking, or mumbling to oneself Sexual abuse Bruises around breasts or genitals Unexplained venereal disease or genital infections Unexplained vaginal or anal bleeding Torn, stained, or bloody underclothing Neglect by Unusual weight loss, caregivers or malnutrition, dehydration self-neglect Untreated physical problems, such as bed sores Unsanitary living conditions: dirt, bugs, soiled bedding and clothes Being left dirty or unbathed Unsuitable clothing or covering for the weather Unsafe living conditions (no heat or running water; faulty electrical wiring, other fire hazards) Desertion of the elder at a public place Financial Significant withdrawals exploitation from the elder s accounts Sudden changes in the elder s financial condition Items or cash missing from the senior s household Suspicious changes in wills, power of attorney, titles, and policies Addition of names to the senior s signature card Unpaid bills or lack of medical care, although the elder has enough money to pay for them

4 OCTOBER 2008 DELHI PSYCHIATRY JOURNAL Vol. 11 No.2 Financial activity the senior couldn t have done, such as an ATM withdrawal when the account holder is bedridden Unnecessary services, goods, or subscriptions Healthcare fraud Duplicate billings for the and abuse same medical service or device Evidence of over medication or undermedication Evidence of inadequate care when bills are paid in full Problems with the care facility:- Poorly trained, poorly paid, or insufficient staff-crowding- Inadequate responses to questions about care Since older persons may present signs and symptoms of a multiplicity of factors due to ageing, such as frail skin, or a fall, or confusion, it is very important to always think broadly in each circumstance and to be alert in order to provide for the safety of the patient and optimal care and to avoid false accusations. Even if the older person doesn t report anything or you don t notice anything unusual on physical examination, it is worthwhile to ask specific questions regarding them having faced any kind of abuse. In a study conducted amongst elderly women residing in shelters in New York, 38% of respondents reported that their medical providers were unaware of their abusive relationship. 3 Screening for Elder Abuse The WHO has put forth some screening tools for increasing the detection of hitherto unreported incidents of elder abuse. The response in the U.K. and U.S. has been pr omising. Some of the recommended screening tools are as follows : Tool Characteristics Validation setting H-S/EAST 15 Items 100 elders living in public Hwalek-Sengstock Elder Older person is the respondent. housing Abuse Screening Test as To identify situations likely to cited by Nelson et al. 4 be or become abusive or neglectful BASE The Brief Abuse Five Items Home assessment of health Screen for the Elderly 5 Filled by trained practioner and social services agency To assess likelihood of abuse cases. with caregiver/elder CASE Caregiver Abuse Eight Items (specifically worded 44 known abusive caregivers and Screen 6 to be non-blaming). 45 non-abusive caregivers Caregiver as respondent. receiving care from a social To identify potentially abusive services centre. Caregivers IOA Indicators of Abuse 29 Items Home assessment of 341 health Screen 5 Trained practitioner to assess and social services agency cases caregiver and elder. (age 55 years and older) To identify abuse among health and social services clients EAI Elder Assessment 44 Items Acute care. Instrument (revised) 7 Trained nurses to identify Individuals at high risk of abuse or neglect who should be referred for further assessment EASI Elder Abuse Suspicion Six items (five questions and one Home assessment of 663 Index 8 observation) respondents by social workers. Older person as respondent. To assess likelihood of abuse 153

5 Why people do not approach help Most people feel ashamed of the fact that they are being ill treated by family members. They are also afraid of retaliation by the family members if the agencies come to help.a large majority also feel that the social agencies could hardly do anything to help them and the major fact was that it was emotionally satisfying to at least be able to see their children. Legal Safeguards in the Indian Context There are numerous provisions set forth by the Indian Law, to ensure the protection of the rights of elder people in their families: The Himachal Pradesh Parents and Dependants Act, 2001 was passed by parliament in 1996, but somehow had to wait for 5 years before being passed by the President s office. It was amongst the first legislations made taking special cognizance of the changing family dynamics in the Indian society. The National Policy on Older Persons, 1999 took 49 years to come, as a logical sequence to the constitutional directive, under the chapter on Directive Principles of State Policy. A National Council for Older Persons (NCOP) was constituted by the Ministry of Social Justice and Empowerment to operationalise the National Policy on Older Persons. Maintenance And Welfare of Parents And Senior Citizens Act,2007 resulted from the evolution of the National Policy on Older persons, over 9 years, and was passed both as an enforceable legislation in its own right, and as a model legislation for state legislatures to promote. Suggestions Though laws are in place, as outlined above, it would obviously be better to sort out the problems amicably. This can be done by having : Special Facilities for the Elderly Facilities like dedicated recreation centres need to be provided to older people to meet like minded people and spend their time doing some constructive social work. Need for professional caregivers is also essential, so that the members of the family who 154 can help monetarily but not with time and energy could get help and therefore some extent of abuse in that direction could be solved. Counselling Counselling has emerged as yet another major component of solving the problem of elder abuse. Counselling of older people to adjust to the needs and changed circumstances of the younger generation can be done, and likewise, the youngsters can be taught to be more considerate towards their elders.counselling could thus prove to be an important component of family therapy and the end result could be beneficial for both the younger as well as the older generation. References 1. Cooper C, Selwood A, Livingston G. The prevalence of elder abuse and neglect : a systematic review. Age Ageing 2008 Mar; 37(2) : Kurrle SE, Sadler PM, Lockwood K, Cameron ID. Elder abuse:prevalence, intervention and outcomes in patients referred to four aged care assessment teams. Med J Aust Feb 3; 166(3) : Bansal SK, Park E, Edwardsen EA. Medical inquiry for intimate partner violence as reported by women in a shelter. J Emerg Med Apr; 34(3) : Epub 2007 Oct Ramsay J et al. Should health professionals screen women for domestic violence? Systematic review. British Medical Journal, 2002, 325 : Reis M, Nahmiash D. Validation of the indicators of abuse (IOA) screen. Gerontologist, 1998, 38 : Reis M, Nahmiash D. Validation of the Caregiver Abuse Screen (CASE). Canadian Journal on Aging, 1995, 14 : Fulmer T et al. Elder neglect assessment in the emergency department. Journal of Emergency Nursing, 2000, 26 : Yaffe M et al. Development and validation of a suspicion index for elder abuse for physicians use: results and implications. Invited presentation to the Ageing and Life Course unit of World Health Organization, Geneva, 14 December Montreal, McGill University, 2004