Abuse of older people
1. Abuse of older people
1.1 A recent House of Commons report suggested as many as 500,000 older people are being abused in England at any one time.1 Abuse is recognised as a growing and significant problem by all agencies which provide care for old people and combined with an emerging body of evidence in both health and social care literature this previously taboo topic is now more widely acknowledged.2
1.2 The British Geriatrics Society (BGS) believes that all specialists working in older people's health care are in a pivotal position to recognise abuse, work with multi-agency teams to investigate cases of concern and develop strategies for prevention.
1.3 Organisations such as Action on Elder Abuse3 and Age Concern4 with others in the voluntary sector have worked tirelessly to raise the profile of this problem but it continues to have a profile way below that of child protection.
2. Defining abuse of older people
2.1 Varying definitions of abuse do not help with clarification of the extent of the problem or development of a body of literature on the subject. (1, 2) Abuse can be 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. The same consistent and comprehensive definition should be used by all health and social care workers, statutory agencies, governments and charitable bodies.
2.2 Abuse is more common in some patient groups such as those with dementia and communication difficulties. Abuse may take many forms but these include physical, psychological, financial, sexual and neglect. Abusers may be a partner, child or relative; friends, neighbours or visitors; other patients or residents; health, social care or other workers: home owners or managers or volunteer workers. 5
2.3 Importantly, abuse can occur in any setting including the older person’s home. Indeed estimates suggest 67% of abuse occurs in their own home, 12% in nursing homes, 10% in residential homes, 5% in hospitals, 4% in sheltered housing and 2% in other locations. 1 Abuse in hospitals particularly those units caring for frail patients with dementia and care homes where over prescribing may be a problem is clearly a major worry and justifies attendant media headlines.
2.4 The BGS fully supports the development of performance indicators to enable accurate measurement of the incidence and extent of abuse recognising that there is likely to be significant underreporting. 1
3. Modes of abuse
3.1 Physical abuse may take a number of forms including hitting, slapping, and use of restraint. It also includes giving too much or too little or the wrong medication and a number of recent murder cases highlight the potential for abuse with medication.
3.2 Psychological abuse can occur with shouting, swearing, frightening, blaming, humiliating or by ignoring and isolating. This can occur in any setting.
3.3 Financial abuse should also be considered and can take the form of illegal or unauthorised use of a person’s property or money. It is much more common in cases of mental incapacity due to dementia and specialist input is vital in this field to avoid fraud and financial irregularities.
3.4 Sexual abuse includes forcing a person to take part in sexual activity without their consent and this can occur in any relationship.
3.5 Abuse can occur by neglect where a person is deprived of both stimulation and company or care needs e.g. placed in a room on their own. It also occurs when a person is deprived of food, heat, clothing and comfort.
3.6 Finally, older people can be subject to racist, religious or other culturally based abuse.
4. Identification of abuse
4.1 Specialist services for older people are in a key position to identify abuse. It is essential that there is mandatory training in the recognition, reporting and management of elder abuse for those professionals working and caring for older people.
4.2 The Single Assessment Process (SAP) introduced in 2004 as part of the National Service Framework (NSF) for Older People 6 provides a crucial opportunity to review the care of the older person. The BGS strongly supports clinicians being at the centre of such assessments.
4.3 Specialists caring for older people who carry out comprehensive assessments both in hospital and the community regularly come into contact with frail older people and those most liable to abuse. Signs of abuse such as repeated hospital attendances, frequent falls and financial impropriety are well described. 2
4.4 Institutional practices such as inflexible routines, use of restraint, and lack of care plans and bullying or patronising attitudes of staff indicate potential or actual abuse. Geriatricians and specialist teams for the elderly who regularly visit such care home and hospital settings are well placed to identify such concerns.
5. Tackling elder abuse
5.1 Since the publication of “No secrets” 5 in 2000 there has been a National framework that requires local council social services to act as lead agencies in the development of local multi-agency codes of practice for the protection of vulnerable adults. All Directors of Social services were required to develop local codes of practice with health and voluntary sector partners and these arrangements were to include an emphasis on prevention and robust measures to address suspected or actual abuse.
5.2 Two subsequent reviews 1, 7 of arrangements for tackling abuse have highlighted the urgent need for improvement in implementation of codes of practice, dissemination of guidance, gathering of performance information and in training of relevant staff. Specialists for older people and their teams are well placed to contribute to audit and the clinical governance relating to abuse of older people.
5.3 Difficulties are not be unexpected as this work involves multiple agencies, require true partnership and needs cultural change that supports activities such as “whistle blowing”. The BGS recommends that all senior management arrangements e.g. multi-agency working groups (adult protection committees) include input from geriatricians and their specialist teams from both hospital and community sectors.
6. Concerns about workers in the care environment
6.1 In June 2004, the Department of Health issued g uidance for the protection of vulnerable adults (POVA) scheme 8 which requires registration of workers in the care environment.
6.2 The BGS fully supports the move to register all care giving groups of staff and the implementation of the Protection of Vulnerable Adults list fully across health and social care settings. Geriatricians are well placed to observe practice and staffing within care homes and should have clear routes to report any concerns.
6.3 Specialist teams for the elderly have a potentially important role in training of groups of staff across the caring sector.
7. The way forward
7.1 The BGS strongly supports all attempts to raise the profile of elder abuse. Geriatricians should continue to champion the issue and highlight the needs of this group of frail older people.
7.2 Specialists caring for older people using the Single Assessment Process and comprehensive geriatric assessment are ideally placed to identify cases of concern. They also should be active in training staff, implementing codes of practice and in the strategic oversight of multi-agency arrangements.
7.3 Real progress must be made with implementation of the key recommendations of No Secrets 5 and the recent House of Commons Health Committee report 1 otherwise abuse will continue to remain hidden and older people will be at significant risk.
1. House of Commons Health Committee. Elder abuse. Second Report of session. March 2004, 1-55.
2. MS Lachs, K Pillemer. Elder abuse. Lancet 364, 2004, 1263-1272. www.thelancet.com
3. Action on Elder Abuse. Astral House, 1268 London Road, London SW16 4ER www.elderabuse.org.uk
4. UK Age concern s. The four nations. www.ace.org.uk
5. Department of Health and Home Office. No secrets: guidance on developing and implementing multi-agency policies and procedures to protect vulnerable adults from abuse. March 2000, 1-42.
6. Department of Health. National Service Framework for Older People. March 2001.1-45. www.doh.gov.uk
7. Centre for Policy on Ageing. No secrets, the protection of vulnerable adults from abuse: local codes of practice. June 2002, 1-12. www.cpa.org.uk
8. Department of Health. Guidance for the protection of vulnerable adults (POVA) scheme. June 2004. 1-45. www.doh.gov.uk
Peter Belfield for BGS Policy Committee