ELDER ABUSE in the ACT A Literature Review

ELDER ABUSE in the ACT A Literature Review COTA (COUNCIL ON THE AGEING) ACT June 2015 Authored by: Eva Cotterell Suzana Leonardi Dianne Coward Jane Thomson Amy Walters

This paper gives a brief summary of the current research in regard to elder abuse - what constitutes elder abuse, why it seen as a problem, and responses to it in Australia and internationally. 1. Why elder abuse is important Elder abuse is firstly a human rights issue. The 1948 United Nations Declaration of Human Rights (UNDHR) highlights the social responsibility of countries to protect the elderly, to offer them appropriate support and services and to promote their right to a safe environment 1. The Second United Nations World Assembly on Ageing in 2002 led to the Toronto Declaration on the Global Prevention of Elder Abuse. The Toronto Declaration called for action by countries: 1) to establish a legal framework, a multi-sectoral plan of action, social marketing and 2) to promote the role of primary health care in the frontline of prevention. In addition, the Madrid International Plan of Action on Ageing encouraged international collaboration to respond to the challenges of ageing, emphasizing the empowerment and protection of the elderly, to defend their rights to a safe environment 2. Elder abuse is also a public health issue. Elder abuse can lead to serious physical injuries and long-term psychological consequences. Many countries including Australia are experiencing rapidly ageing populations; the global population of people aged 60+ years is expected to double between 1995 and 2025. Therefore, the incidence and cost of elder abuse is likely to increase. 3 2. Definition of Elder Abuse The International Network for the Prevention of Abuse of Older People (INPEA) and the World Health Organisation (WHO) define Elder Abuse 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. Abuse of older people can be of various forms such as physical, psychological/emotional, sexual and financial. It also reflects intentional or unintentional neglect. 4 The definition of older person varies, as does eligibility for services for older persons. In Australia, access to the age pension is 65 years, and access to aged care services generally starts at 70 years. However, access for Aboriginal and 1 WHO, "European Report" 9 2 WHO, "European Report" 9 3 WHO Fact sheet No 357 Elder Abuse 4 WHO Fact sheet No 357 Elder Abuse

Torres Strait Islander people is often reduced to 45 or 50 years because of their lower life expectancy. 5 3. Risk Groups Abuse of older people crosses gender, socio-economic, religious and cultural boundaries. Abuse is more likely to be inflicted by family members, especially an older person s adult children. 6 Older people are at increased risk of abuse when they Have a disability or poor health; Are in dependent caring relationships, particularly where a carer is experiencing carer burden or carer stress; Are isolated and/or without personal supports; Have a past history of violence or conflict within the family; Exhibit particularly difficult and/or inappropriate behaviour, and/or confusion or memory loss; or Exhibit signs and symptoms of dementia. 7 4. Forms of abuse of older people Elder abuse is generally divided into the following categories: Physical abuse the infliction of pain or injury, physical coercion, or physical or drug induced restraint; Psychological or emotional abuse the infliction of mental anguish; Financial or material abuse the illegal or improper exploitation or use of funds or resources of the older person; Sexual abuse non-consensual sexual contact of any kind with the older person; Neglect the refusal or failure to fulfil a care giving obligation. This may or may not involve a conscious and intentional attempt to inflict physical or emotional distress on the older person; Social abuse preventing a person from having contact with friends or family, or access to social activities. 8 5 ACT Elder Abuse Prevention Program Policy, June 2012 6 National Centre for Elder Abuse, Administration on Ageing, USA 7 Podneiks, E et al (1990) National Survey on Abuse of the Elderly in Canada, Ryerson Polytechnical Institute, Toronto 8 WHO, The World Health Report on Violence and Health, Ch 5 http://www.who.int/violence_injury_prevention/violence/world_report/chapters/en/

5. Extent of elder abuse While there is little information regarding the extent of abuse in elderly populations, especially in developing countries, it is estimated that 4-6% of elderly people report significant abuse in the last month. However, older people are often afraid to report cases of abuse to family, friends, or to the authorities. 9 6. Differences in regard to CALD and indigenous communities The literature suggests that definitions of abuse need to be redefined in a cultural context, as a different cultural view affects the way that elder abuse is perceived. Cultural context includes language, literacy, family status, community norms, spiritual beliefs and life experiences. Points to be noted include: Older people from CALD communities are often more dependent on their families and carers for basics such as doctors, banks, services and support. For example: In many cultures, the husband controls finances and upon his death, the son takes over so that the widow remains unaware of her financial resources, and vulnerable to abuse. 10 As people age, they often lose their second language, but are dependent on family and carers in situations that require English language. This is particularly important in relation to health care, financial and legal processes where, if an accredited interpreter is not used, the interests of family members or carers may affect the translation. 7. Indigenous communities Because of shorter indigenous life expectancy, older for Aboriginal and Torres Strait Islander Australians can be defined as from 50-55 years of age. The term Elder has different meanings for different Aboriginal communities. Elder can be any respected member of the community regardless of age. Some authors prefer the term maltreatment of older adults in indigenous communities. Cultural obligations to share can lead to exploitation of older adults; intergenerational emotional abuse can result when elders are no longer respected by younger people; violence and neglect can be related to alcohol and drug abuse; the importance of family can be a barrier to taking any action that separates or divides the family. 11 9 WHO Fact Sheet No 357 10 Multicultural Community Care Service Inc, Thinking outside the square, defining elder abuse in culturally and linguistically diverse communities, COTA National Elder Abuse Conference, Perth, 2014 11 Wilkes, T, Elder abuse in an Aboriginal community setting, COTA National Elder Abuse Conference, Perth 2014

8. Current situation in Australia and the ACT specifically In Australia, elder abuse is primarily a State/Territory responsibility. The Federal Government s power is limited to reporting and complaints about residential aged care facilities, which affect only a small percentage of aged persons. Table 1 outlines the history of the development of State Government policies and programs. In summary, several major studies on elder abuse were conducted in the late 1980 s, followed by the development of policies and programs to address the problem. In the last 10 years, these policies and programs have been reviewed. Media reports of elder abuse in aged care institutions as well as individual cases of neglect by family members have been effective catalysts for the review process. A further prompt for action has been the realisation that Australia s population is ageing rapidly, with prediction of numbers increasing from 16% of the population in 2010 to 22% by 2030 12. Table 1: History of State Government Elder Abuse Policies and Legislation Year New South Victoria South Queensland Wales Australia Late Major studies around elder abuse 1980 s 1991-1995 1996-2000 2001-2005 Task force, discussion paper, public consultations; Elder Abuse Subcttee formed; Cross agency protocol to assist older people being or suspected of being abused Research report, and funding to implement recommendations aimed at whole of govt response Abuse Prevention Program for people in residential aged care; Program extended to people living in the community Alliance for the Prevention of Elder Abuse (APEA): govt agencies including police to improve response to elder abuse Report on abuse of older people Elder Abuse Prevention Unit formed Adult Guardian position established Domestic violence laws amended to 12 ACT Elder Abuse Prevention Program Policy, June 2012

2006-2010 2012-2015 Media publicity about abuse in nursing homes; Legislation to criminalise failure to provide necessities of life NSW Ageing Strategy including helpline, updated interagency protocol for responding to elder abuse Specialist older persons legal service, helpline, advocacy & support, community education; Updated guidelines for health services, community agencies Guidelines on govt priorities and action; protection orders in cases of violence; Legislation to clarify Power of Attorney duties, and protection for person whose affairs are being dealt with 2016- Commission into Family Violence will report Feb 2016 Our Actions to Prevent the Abuse of Older People: policy and framework for safeguarding older people, and abuse prevention and response. Charter of Rights and Freedoms of Older People Strategy for Safeguarding Older People include elder abuse Seniors Task Force formed Free legal and support service for elder abuse, mistreatment, financial exploitation Media publicity about Cynthia Thoresen and her abusive daughter Coroner recommended law reform to criminalise mistreatment of older people In the ACT, the Legislative Assembly initiated an enquiry into elder abuse in 2001 13, and in response to its recommendations, the Elder Abuse Prevention Program was developed. The ACT Government allocated funding over four years in their 2003-4 budget to develop a program to respond to elder abuse or suspected elder abuse, which included a telephone information and referral service, a community awareness campaign, development of training materials for professionals, and an ACT Elder Abuse Policy Framework. In October 2008, the then Department of Disability, Housing and Community Services commissioned Communio Pty Ltd to undertake a strategic review of the program. Key recommendations included developing a more coordinated and multidiscipline approach, creating policies and guidelines for ACT government 13 Elder Abuse in the ACT, Standing Committee on Health and Community Care, 2001

agencies, developing better information, screening, referral and response processes for agency staff, raising community awareness, and gathering more consistent data. The ACT government s ACT Elder Abuse Prevention Program Policy was finalised in June 2012. The Policy is coordinated by the Office for Ageing and the Community Services Directorate, with advice from the Elder Abuse Prevention Network and the ACT Ministerial Advisory Committee on Ageing. The government also provides an elder abuse hotline, APRIL (Abuse Prevention, Referral and Information Line). The ACT government acknowledges that elder abuse is a fundamental breach of human rights, and recognises elder abuse according to the standard definition of any behaviour or action within a relationship of trust that harms an older person. It includes financial, psychological, physical, sexual, social abuse and neglect. The true incidence of elder abuse in the ACT is unknown. There are many reasons for this including difficulties in collecting information about the issue due to its complexity with regard to family dynamics, and the acute vulnerability experienced by victims which prevents them from reporting abuse. However, the ANU Baseline Survey on Canberra as an Age-Friendly City conducted in 2011 14 indicated that 6% of respondents experienced some type of elder abuse. We can assume this is a conservative figure. The ACT has one of the fastest ageing populations in Australia, presenting a concern for the future increase of elder abuse. Apart from the Office for Ageing, a number of agencies contribute to the policy agenda and provide services in relation to advocacy, law and (when it arises) elder abuse: The ACT Disability, Aged and Carer Advocacy Service (ADACAS) provides information or advocacy assistance over the phone or in person in relation to the rights of older people and complaints in regard to aged care services. The ACT Human Rights Commission has a Health Services Commissioner (Mary Durkin) has responsibilities for services for Older People. The Health Services Commissioner's mandate is to deal with complaints about the provision of health services and services for older people, and complaints about contraventions of the privacy principles or of a consumer's right of access to his or her health records under the Health Records (Privacy and Access) Act 1997. The Commissioner's role is also to promote: improvements in the provision of health services and services for older people the rights of users of health services and services for older people an awareness of the rights and responsibilities of users and providers of health services and services for older people. Carers ACT is an advocacy and support service for individuals and families who care for an older person or a person with a disability. They provide advice on appropriate care in aged care facilities and assist cares to look after themselves to avoid carer stress, which is a risk factor for elder abuse. 14 A Baseline Survey of Canberra as an Age-Friendly City, Centre for Mental Health Research, Australian National University, 2011, at http://www.cepar.edu.au/media/112955/age_friendly_canberra_final_version.pdf

Care Inc. is a non-profit community legal centre that provides free legal advice and assistance to low and moderate income consumers. The CLC also makes regular submissions to government with the aim of improving access to justice for our community s vulnerable and disadvantaged, including older people. COTA ACT has a housing service that provides advice to older people on accessing home care packages and community support systems which can assist older people to maintain some independence. Legal Aid ACT provides legal advice and representation to socially and economically disadvantaged people. A priority area is family violence and breakdown. The Public Advocate of the ACT advocates on a range of matters affecting older people in the ACT, including on enduring power of attorney and financial management. The Public Trustee of the ACT can provide assistance with administration of financial affairs when people are legally incapable and have not prepared an Enduring Power of Attorney. 9. International best practice It is difficult to compare information from different countries on the topic of elder abuse due to the lack of high quality long-term national surveys and research, as well as the use by each country of different methodologies and definitions 15. Despite the obstacles to data comparison, the United States is the most developed in terms of domestic-level response to elder abuse 16. Domestic responses worldwide Most of the programs set up to tackle abuse in high-income countries operate as part of social services, health care and legal systems in conjunction with programs to combat family violence. Generally, these services are offered through a network and involve medical, legal, ethical, psychological, financial, law enforcement and environmental support. Guidelines, protocols and special training are developed to help caseworkers. Care is usually planned by consulting teams drawn from different disciplines, which work in collaboration with task forces. These countries frequently offer a telephone helpline to receive reports of mistreatment. One example of such a response is the Adult Protective Services in Israel. These units are multidisciplinary, formed by social workers trained in geriatrics, legal experts and health care professionals. Their goal is to improve identification of elder abuse and to create modes of intervention at individual and community levels 17. Training and education is deemed important to not only raise awareness regarding abuse, but also to teach individuals to identify and deal with suspected cases. For example in Germany, courses run by the Police University in Münster educate nurses and middle managers to identify abuse and intervene in a professional 15 WHO, "World Report" 125; WHO, "European Report" 60 16 WHO, "World Report" 134 17 WHO, "World Report" 136

manner. These are taught through workshops and formal lessons and provide information on elder abuse, risk factors, screening, communication in critical care situations and legal issues 18. Educational campaigns for possible victims are also perceived as crucial to inform older people of acceptable behaviors. The Canadian mass media campaign "Respect our Elders" is a good example of a campaign through newspapers, TV, radio, meals-on-wheels and centres for older people. It included personal stories of abuse and a report explaining how to deal with abusive situations. Victims were directed to adult protection services and a helpline 19. Helpline services are offered free of charge and provide emotional support, information and occasionally referrals to local and national support services. In some cases, they also provide follow up services and ongoing support for victims. For instance, the National Network Helpline Center in France supports and protects victims of elder abuse. It runs according to local needs and is operated by trained volunteers, many of whom retired from experiences in health or social care. 20. With increased interest in providing services for victims of elder abuse, the support offered is becoming similar to those developed for battered women. Countries have been adapting existing emergency shelters to also support the elderly who are victims of abuse. Germany is a good example of this practice, working with existing shelters, perceived as places to protect only women and children, to alter how the public sees them and to broaden the targeted age range. Other countries are even creating new services focused on the needs of this specific group. The Weinberg Center for Elder Abuse Prevention in New York is an example of a shelter that has been designed to help the elderly with emotional support, counselling, legal assistance, health care and to find long-term safe accommodation 21. Psychological programs for abusers aim at reducing factors that contribute to abuse, such as anger and stress. These programs attempt to combine psychological components with education on the person's illness, the ageing process and elder maltreatment. In the United Kingdom, for instance, education and anger management is offered to informal caregivers to reduce conflict behaviours, stress in caregivers, depression and anxiety 22. One example of an organizational intervention to improve professional practices through guidelines, referral protocols and supporting provision of high-quality care operates in the United Kingdom. It provides a multidisciplinary team that aims to increase standard of care, through managing the interface between nursing homes and primary care. It also supports nursing homes by promoting teamwork and professional development, putting importance on person-centred care and encouraging staff to examine care practices. The work of this team is to audit, offer 18 WHO, "European Report" 45-46 19 WHO, "European Report" 47 20 WHO, "European Report" 50 21 WHO, "European Report" 50-51 22 WHO, "European Report" 51

workshops with guidance and facilitated discussions, help access to e-leaning resources, provide community services and give formal training of staff 23. Some interventions combine more than one approach to address abuse. The US presents a multi-component program to improve reporting and management of abuse. This is done through courses that cover: abuse, dementia, effective interventions to deal with suspected cases, screening tools to identify abusive behaviour, referral protocols for staff and volunteers in protective services. They also provide a handbook for caregivers of people with dementia who experience stress, which provides information about risk of harm to caregivers and patients with dementia, as well as self-assessment instruments to identify stress and point to where to get help 24. It is widely believed that health care plays an important role in screening and detecting abuse because of the constant contact of the elderly with doctors and nurses. This puts those professionals in an ideal position to identify and support those at risk of experiencing abuse. Nonetheless, in the majority of countries professionals are not trained to play this role 25. Most countries have not introduced specific legislation on elder abuse, but particular aspects of abuse are usually covered by criminal law, laws dealing with civil rights, property rights, family violence and mental health. Specific and comprehensive legislation would imply stronger commitment to eradicate the problem. Nevertheless, even where that legislation exists, cases of elder abuse are rarely prosecuted. This can be explained by the fact that people are reluctant to press charges against family members, the elderly are often regarded as unreliable witnesses and this crime has an inherently hidden nature 26. It is also related to the fact that, dissimilar to child abuse, older people are adults, with all the rights and responsibilities that entails (eg the right to make legal, financial, health and other choices, and the right to privacy). Mandatory reporting is considered to be a valuable tool, particularly in situations where victims are not able to report and professionals are reluctant to refer cases..reporting laws define responsibilities, establish official procedures for making reports and create a system to receive and investigate them. Nonetheless, the US General Accounting Office found that reporting does not prevent abuse and is not the most efficient tool to identify the cases. Indeed, it holds the view that the most successful way for identifying mistreatment is public and professional awareness, while for preventing and treating is the provision of in-home services. WHO also points to the same direction when it mentions that reporting is less due to legal requirements than to organizational, ethical, cultural and professional factors 27 The European Union Report identified the following challenges faced by Europe and worldwide in the fight against elder abuse: 1) mortality data for homicide does not capture the perpetrator relationship to the victim and thus overlooks the maltreatment that leads to the homicide; 2) there are few routine data on elder abuse 23 WHO, "European Report" 52 24 WHO, "European Report" 52-53 25 WHO, "World Report" 137; WHO, "European Report" 45 26 WHO, "World Report" 138 27 WHO, "World Report" 138; GAO, "Alder Abuse" 2

due to underreporting from health care, police and social services; 3) there is a lack of long-term national surveys with standardized methodology; 4) there is a need for better designed studies to determine risks, causes, effects and actions to fight abuse; 5) there is a need for high quality studies to assess effectiveness of the interventions specifically designed to prevent and respond to abuse and 6) there is a need to use evaluative framework in programs addressing abuse to determine which is more effective 28. The United States case The United States presents the most developed system for reporting and treating elder abuse. This system is mostly based on state or local responses. There is no national program or funding to coordinate these state and local actions. The federal government's role is limited to supporting the National Center on Elder Abuse which provides assistance to the states or local communities with: information, technical assistance, training and small amount of funding for abuse prevention 29. The primary agency at the state level is the Adult Protective Services Program (APS). Its role is to identify, investigate, resolve and prevent elder abuse. APS is usually administered by local or state health, aging or regulatory department and includes a multidisciplinary approach to supporting victims. Without a national program, each of the states has created its own legislation, definitions and APS 30. Despite the differences, the APS agencies are guided by the same basic principles: the client's right to self-determination, the use of the least restrictive alternative, the maintenance of the family unit whenever possible, the use of community-based system rather than institutions, the avoidance of blame and the view that inadequate and inappropriate services are worse than none 31. Most APS agencies follow a similar model of protective service delivery, based on social casework and systems approach. It usually provides a coordinated, interdisciplinary multi-step program of social and health services at the state level. Examples of services arranged include emergency shelters, emergency in-home protection, emergency food, emergency medicine and medical care, counselling and money management assistance 32. If the abuse is substantiated and involves criminal activity, it is referred to a prosecutor. In extreme cases, when the older person is unable to manage his or her own affairs, a court may appoint a guardian to help them to make decisions 33. All of the APS agencies cover the main forms of abuse: physical, emotional, sexual, financial abuse and neglect. The majority of them also support victims of selfneglect. 34 They also provide services in community settings and most of them 28 WHO, "European Report 2;5;13;43;45;54;61 29 WHO, "World Report" 134; "About"; GAO, "Elder Abuse" 2 30 "Elder Abuse" GAO, NAPSA, "Adult Protective Services" 2;15 31 NAPSA, "Adult Protective Services 32 NCEA, "15 Questions" 11 33 GAO, "Elder Justice" 20 34 GAO, "Elder Justice" 4 & 20.

investigate cases in long-term care facilities as well. The latter activity is shared with the Long-Term Care Ombudsman and other regulatory agencies 35. All states have enacted laws that specifically deal with elder abuse. In some states, the law protects elderly only from domestic abuse and in others it also covers institutional maltreatment (GAO, "Elder Justice" 3-6). Almost all states have mandatory reporting laws 36. Shortcomings of this model include: 1) APS agencies face increasing numbers and complexity of cases, but funding for staffing, training and public awareness is not keeping pace; 2) lack of access to information on how to resolve abuse cases, such as effective interventions, recommended case load size and appropriate outcome for cases; 3) some APS agencies lack adequate administrative data as they face challenges in collecting, maintaining and reporting state-wide case level data and their data methodology differs from other states; 4) lack of adequate collaboration between APS and other agencies and 5) lack of federal leadership 37. 10. Conclusion Despite the international strategies discussed above, more action is needed to adequately reduce elder abuse and achieve a more caring society. Key steps to the achievement of this goal include: investment in long-term routine standardized and systematized local and national data collection, high quality validated research and evaluative research of practices. effective regulatory bodies to regulate, inspect and provide quality assurance to institutions that take care of the elderly 38. policies and plans at a national level to prevent and tackle this type of abuse 39. Legislative change where required to protect and support vulnerable older people. inter-sectoral coordination to improve the effectiveness of prevention strategies 40. 35 NAPSA, "Adult Protective Services" 2-3; "History" 36 History"; GAO, "Elder Abuse" 15-16 37 GAO, "Elder Justice"17-23 38 WHO, "European Report" 2, 5, 13, 43, 45, 54, 60, 61; WHO, "World Report" 134; Bonnie and Wallace 7; GAO, "Elder Justice" 23 39 WHO, "European Report" 63 40 WHO, "European Report" 64

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