Elder Abuse: Policy, Practice and Research OPAN 15th November 2006

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Elder Abuse Policy, Practice and ResearchOPAN
15th November 2006

• Jayne Elias (Challenger)
• Consultant Nurse
• Caerphilly Local Health Board

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How big is the problem of elder abuse?
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The problem

• 500,000 older people are believed to be abused
  at any one time in the UK. On the basis of this
  figure, we can estimate that 50,000 older people
  in Wales are experiencing abuse. However, less
  than 1,000 cases were reported to the appropriate
  authorities in Wales during 2004/05. This shows
  that potentially a significant number of cases of
  elder abuse in Wales, if not the vast majority,
  remain undetected
• (Ana Palazón, Help the Aged, Wales)

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Media interest..

• News article (source BBC online news) 5th June
  2006 Elderly abuse 'becoming common
• Abuse and neglect of elderly people in Britain
  has become widespread, according to a survey of
  1000 people aged 16 and over commissioned by
  Radio 2

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Findings of the survey

• A quarter said they knew an elderly person who
  had been mistreated
• 1 in 10 cited examples of physical abuse
• Cases of elderly people being left unfed and
  humiliated were highlighted
• More than half believed that there was a great
  deal of neglect and mistreatment of older people
  in Britain
• Most believed the majority of neglect and
  mistreatment occurred in care homes (53) and
  hospitals (48)

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Prevalence

• Research to identify extent of abuse is limited
• Estimates of prevalence have tended to be
  generalised from (often dated) studies or from
  cases reported to help lines e.g. Action on Elder
  Abuse (Select Committee on Health, 2004)
• Lack of accepted definition, and lack of a single
  method of detection and assessment have led to
  difficulties estimating prevalence

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Local statistics POVA referrals within
Caerphilly County Borough
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Defining Abuse and Neglect

• Abuse is the violation of a persons human or
  civil or legal rights by another person or
  persons
• Abuse may be a single act, repeated acts and/or
  multiple acts. It may be physical, verbal,
  emotional or psychological. It may be perpetrated
  as a result of deliberate intent, negligence or
  ignorance
• Source SE Wales Protection of Vulnerable Adults
  Guidelines

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Elder/adult abuse generally has two
characteristics

• An injury or deprivation has occurred to the
  vulnerable adult
• Someone else bears responsibility for causing the
  injury or deprivation or failing to prevent it

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Local picture categories of abuse by age
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Identifying risk factors for elder abuse

• In order to initiate effective methods of
  treatment and prevention, practitioners need to
  understand which factors put older people at risk
  of abuse
• Decreasing risk factors and increasing protective
  factors are the first steps in addressing elder
  abuse

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Recognised risk factors in elder abuse

• Moraru, 2006 suggests
• Cognitive impairment
• Physical impairment
• Decreased functional ability
• Depression
• Dependency on others for care or food
• Dependency on others for management of finances
• History of family violence
• Refusal of outside services
• Poor social network or social isolation

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Who are the Victims?

• Elder abuse occurs irrespective of ethnic
  background, religion, social status, or gender
• Older people who are frail or ill are at a higher
  risk (healthy older people also may be in an
  abusive situation or relationship, Age Concern,
  2001)
• Elder abuse occurs within the context of a
  relationship, usually with a person in a position
  of trust

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Studies show those most at risk are

• Female
• Aged 75 and over
• Frail and or suffering from chronic conditions
• Dependent on others for care
• Physically or socially isolated

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Local picture (2005/06)

• Summary of all adult referrals in Caerphilly
  Borough highlights the vulnerability of older
  women to abuse

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Where is abuse occurring in CCB?
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Where does elder abuse occur?

• The living situations of many older adults can
  make them vulnerable to abuse and create barriers
  for intervention
• An abusive family member may be one of the few
  people who has contact with an older victim,
  creating few opportunities for outsiders to
  suspect abuse and intervene
• Older adults living in care homes may have mental
  and physical illnesses or be socially isolated
  making it difficult to detect physical or
  emotional abuse, medication misuse, or neglect

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CSIW Annual Report 2005/06 comments

• whilst there is evidence of good quality care,
  the improvements identified last year have not
  been sustained. There remains a gap between what
  service users have a right to expect, through the
  regulations and national minimum standards, and
  the findings in a significant number of care
  homes across Wales. This includes concerns about
  core aspects of care and support for service
  users in particular case planning and management
  of medication (pg 90)

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Identifying the most vulnerable

• CSIW in their Annual Report (2005/06) report that
  they were involved in 475 adult protection
  investigations involving 555 service users across
  all categories of abuse - the highest number
  concerned physical abuse and neglect
• Whilst care homes with nursing account for 25 of
  the market 64 (305) of all adult protection
  investigations occurred in these homes

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Case example 8th November 2000

• A male nurse who worked a 12 hour night shift
  at a nursing home while holding down a hospital
  day job was yesterday jailed for four years after
  being convicted of poisoning a patient in his
  care in an attempt to endanger his life.
• Reed, a father of three, was said to have
  administered non-prescribed drugs to patients "to
  lighten his workload" while working long hours at
  the Bedwellty nursing home, in Aberbargoed, and
  Tonteg hospital, Church Village.

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US perspective

• Professor Catherine Hawes in a testimony to the
  US Senate Committee on Finance, 2002 reported
• There is no reliable data on the prevalence of
  abuse or neglect in nursing homes or residential
  long term facilities. However the piecemeal
  evidence we do have suggests the problem is
  serious and widespread

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• Evelyn Pringle Little Rock, AR September 12,
  2006..
• In 1987, Congress passed landmark legislation
  aimed at improving nursing home care for the
  nation's vulnerable elderly population. However,
  a recent investigation by Consumer Reports found
  poor care in nursing homes is still extremely
  common, especially in the for-profit chains that
  have become the dominant force in the industry.

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Why does elder abuse occur?

• Elder abuse, neglect, and exploitation often go
  unrecognised and unreported
• Family /care-giving dynamics often play a role
  some older adults may rely on their
  children/family members for physical care. Family
  members may depend on the older adult for housing
  or financial support
• These interdependencies can frame the context for
  exploitation and abuse

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Why does elder abuse occur?

• No one explanation exists for elder abuse and a
  combination of factors may contribute to the
  problem
• characteristics of the caregiver (addiction or
  personal problems)
• Characteristics of the victim (physical or
  cognitive impairments)

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Why does elder abuse occur?

• Family Dynamics A history of domestic abuse or
  strained relationships, family stress, financial
  pressures, and social isolation may be causative
  
• Cultural Values society's perceived
  preoccupation with youth can imply that older
  people are not valued and elder abuse tolerated
• Beliefs that behaviour within the family are
  family matters or belief systems that diminish
  the rights of some family members can foster an
  environment that tolerates abuse.

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Barriers to disclosure

• Family structure, cultural beliefs, generational
  issues, and language barriers may affect the
  willingness of older people to communicate
  instances of abuse with people considered as
  outsiders. Practitioners must approach elder
  abuse with cultural competence
• Communication must convey the universal message
  that abuse is illegal and the rights of
  individuals will be protected.

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Barriers to Disclosure

• Shame
• Guilt
• Dependency on abuser/alternatives
• Love of abuser/consequences
• Being believed
• Is it abuse?

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Assessing the risk

• Assessing the risk of abuse or exploitation
  requires consideration of a number of issues
  regarding
• The older person
• The caregiver
• The environment

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Theories of Adult Abuse

• Elder abuse is complex making it difficult to
  construct one theory to explain the causes of
  elder abuse
• There is overarching uncertainty about how elder
  abuse fits within other theoretical frameworks
  related to violence parallels can be drawn
  between elder abuse, child abuse and domestic
  violence (Dunlop et al, 2000)
• Elder abuse shares many characteristics with
  child abuse and domestic violence
• Victims who are vulnerable
• Similar perpetrator characteristics
• Effects of the abuse on the victim
• Difficulties associated with interventions to
  stop the abuse
• A growing perception of the abuse as a recognized
  social problem

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Theories of Adult Abuse

• However elder abuse also creates its own set of
  problems and challenges for professionals, family
  members, and others concerned with the well-being
  of vulnerable adults
• There is need to understand the range of elder
  abuse including self-neglect, abuse and neglect
  within the family, and abuse that occurs in
  institutional settings

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Who Are the Abusers?

• Ramsey-Klawsnik (2000) suggests five types of
  offenders
• Overwhelmed offenders enter a caregiving position
  expecting to provide adequate care, but the
  amount of care exceeds their capacities
• Impaired offenders have problems that render them
  unqualified to provide adequate care, such as
  advanced age and frailty, physical and mental
  illnesses, and developmental disabilities
• Narcissistic offenders are motivated by personal
  gain, not the desire to help others, and may
  neglect or financially exploit older adults
• Domineering or bullying offenders believe their
  actions are justified and the victim "deserved"
  the abuse
• Sadistic offenders derive feelings of power and
  importance by humiliating, terrifying, and
  harming others

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Who Are the Abusers?

• (House of Commons select committee on health,
  2004).
• Paid carers - UK data indicates this group
  represents 31 of abusers. This form of abuse is
  usually associated with physical abuse and
  neglect
• Family members or other persons related to the
  victim - 47 in the UK. Often associated with
  psychological and financial abuse

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Caerphilly data is consistent with evidence base
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Elderly abuse Case study (Wednesday, September
8, 1999 Published at 1233 GMT 1333)

• Cases of abuse have been highlighted by numerous
  media campaigns. BBC News Online examines one of
  the most brutal. Assault
• A nursing home worker was jailed for four years
  in July for abusing eight elderly women in his
  care. Twenty-eight-year-old Simon Hack admitted
  one charge of causing actual bodily harm, three
  indecent assaults on women in their 80s and 90s
  and four of common assault. Hack, who doctors
  said had a deep-seated hatred of women, worked
  for Sunways Nursing Home in Aldershot, Hampshire,
  from 1991 to 1996. The prosecution said he seemed
  to target the frail and vulnerable and those who
  could not protect themselves. The accusations
  against Hack included allegations that he poured
  cold water over a 78-year-old woman and put a
  stocking over her head, grabbed a 92-year-old
  woman's breasts, force-fed a 96-year-old and
  poured sherry down the throat of an 81-year-old,
  causing her to choke. The prosecution said there
  had been over 100 complaints made about him.

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Elder abuse within care homes

• American study found within the residential
  long-term care setting, situational factors have
  been found to contribute to elder abuse
• Staff shortages and stressful working conditions,
  including mandatory overtime
• Staff burnout
• Poor staff training on handling challenging
  behaviours among residents, such as aggression
• Hawes (2002)

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CSIW findings

• In their Annual Report for 2005/06 CSIW identify
  issues in the care home sector related to
• Quality of home management
• Lack of adequate Quality Assurance Systems
• The suitability and quality of staff
• Inadequate staff training

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Intentional?

• Intentional abuse is a conscious and deliberate
  attempt to inflict physical, emotional, or
  financial harm, often due to a need for control
• Unintentional abuse is an inadvertent action
  resulting in physical, emotional, or financial
  harm, usually due to ignorance, inexperience,
  lack of desire, or inability to provide proper
  care

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Minimising abuse through recognising risk factors

• Recognizing the context of the relationships in
  which elder abuse occurs is important
• The characteristics of the caregiver/perpetrator
  are better predictors of elder abuse than victim
  characteristics
• Emphasis must be put on changing the dynamics of
  the relationship to ensure behaviours of the
  perpetrator are addressed. It is important to
  hold abusers accountable and to address
  situational factors conducive to abuse.

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Consequences of Abuse and Neglect

• Unnecessary suffering, pain, injury, loss and/or
  violation of human rights, and decreased quality
  of life
• Older adults who are abused and neglected are
  three times more likely to die than those who are
  not abused (Dyer et al, 2003)

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Why is elder abuse difficult to address?

• Moraru, (2006) suggests
• Lack of time, concern, knowledge, and awareness
  of elder abuse contributes to its perpetuation
• Lack of political interest resultant of ageism,
  lack of status of older people and other problems
  competing for attention

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Attitudes to older people

• Older people are a big headache and a waste of
  scarce resources the biggest favour you could do
  to me as an older peoples organisation is to get
  them out of my hospital
• Comments of a Kenyan healthcare professional to
  the WHO and International Network for the
  Prevention of Elder Abuse (INPEA) in 2002

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Why is elder abuse difficult to address?

• Medical knowledge regarding elder abuse and
  neglect is developing (unlike in child abuse and
  domestic violence where it is advanced)
• Many health practitioners can have difficulty
  distinguishing between changes related to aging
  and signs of abuse or neglect - are the bruises
  on an older patient the result of an accident or
  an act of abuse?
• Practitioners need training in identifying
  suspicious-looking bruises and other signs

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Why is elder abuse difficult to address?

• In addition to barriers to treatment and
  intervention for elder abuse, barriers exist to
  prosecution of abusers
• The death of an older person, despite signs of
  abuse, may not be as closely scrutinized as the
  death of a younger person, particularly if
  medical or psychological conditions related to
  aging are observed
• Wales in common with England and N. Ireland does
  not have separate laws that deal specifically
  with adult abuse

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Prevention

• Vulnerable Adults must be supported to protect
  themselves by
• Having understandable and accessible information
  about what constitutes abuse and what to do if
  they are abused
• Having support from user groups where they can
  talk about things that concern them
• Having an advocate who can speak up and take
  action on their behalf if needed
• Taking part in decisions that affect their lives

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Staff can minimise risks by

• Understanding what constitutes vulnerability and
  abuse
• Knowing what to do if abuse is suspected
• Understanding that early recognition can help
  effective intervention
• Understanding that they have a duty of care to
  vulnerable adults
• Discussing care issues and concerns
• Questioning care practices that may be harmful or
  abusive, and taking further action, e.g.
  Whistle-blowing if their concerns continue
• Taking part in training and skills development

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The service can minimise risk by

• Making sure the service meets the needs of the
  vulnerable adult e.g. pre placement assessment
• Appropriate recruitment processes
• Having adequate staffing levels
• Making sure staff know what constitutes abuse and
  what to do if they suspect it
• Having efficient complaints, recording and
  reporting systems including incident review
  procedures
• Policy development

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References

• Care Standards Inspectorate for Wales (2006)
  Annual Report 2005/06. Cardiff WAG
• Dunlop, B.D., Rothman, M.B., Condon, K.M.,
  Herbert, K.S., and Martinez, I.L. (2000) Elder
  abuse Risk factors and use of case data to
  improve policy and practice. Journal of Elder
  Abuse and Neglect, 12(3/4), 95-122.
• Hawes, C. (2002) Elder abuse in residential
  long-term care facilities what is known about
  prevalence, causes and prevention. Testimony
  before the US Senate Committee on Finance.
• House of Commons . The United Kingdom
  Parlimentary Select Committee on Health. Minutes
  of evidence memorandum by Action on Elder Abuse,
  2004.
• Moraru, M. (2006) Elder Abuse. Student BMJ, 14,
  pg164-166
• Ramsey-Klawsnik, H. (2000) Elder abuse
  offenders A typology. Generations, 24(2) 17-22
• World Health Organisation and INPEA (2002)
  Missing voices views of older people on elder
  abuse. Geneva WHO

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Thank you for listening Jayne.Elias_at_caerphillylh
b.wales.nhs.uk