Elder Abuse is the hidden shame of Ireland’s caring industry. The exact incidence and extent of the phenomenon is unknown and probably unknowable. Many factors stand in the way of proper reporting of the abuse, as the victims are often unable to formulate clearly the abuse that they are suffering, or because they fear estrangement from those who are caring for them.
Dr Des O’Neill is a consultant geriatric physician at Tallaght Hospital who leads the national Age-Related Healthcare Project. He is also a member of the Department of Health’s working group on the issue of elder abuse. He believes that incidents of elder abuse are both under-reported and under-acknowledged in this country.
“There has been almost no research into elder abuse in Ireland, but we have no reason to think that the extent of the problem here is any different to anywhere else”, he explains. “Research elsewhere has shown that between 3% and 5% of older people experience regular abuse in some form”.
A study into elder abuse by the National Council for Ageing and Older People estimated that as many as 12,000 older Irish people might be suffering from some form of abuse at any given time. The report, ‘Abuse, neglect and mistreatment of older People’ found that the reluctance of society to recognise the problem of elder abuse is merely following a pattern of how such abuses come to be accepted.
“The slowness to accept the existence of elder abuse is common to other forms of family violence such as child abuse and domestic violence”, according to Anne O’Loughlin and Dr Joseph Duggan in their report.
“In Ireland the message that physical, sexual and mental abuse of women and children in their own homes by known men is unacceptable is only beginning to become part of the public agenda”, the say. “With regards to the abuse of older people, it is unclear whether Ireland is ready to examine and deal with the problem in an open and honest fashion”.
Britain, however, has not been as cautious in confronting this secret shame. In the UK, a ‘No Secrets’ policy was launched two years ago to combat the level of domestic and institutional abuse of older people. One of the controversial aspects of the programme was the introduction of a legal requirement on healthcare workers to report any suspected incidents of abuse – the so-called ‘whistle blowing’ clause.
This is one of the options being considered by the Department of Health’s working Group on elder abuse. The group was set up in January 2000 and is expected to report by January 2002. A wide range of workers who deal with older people are represented on the group, including doctors, social workers, gardai, public health nurses, psychiatrists and nursing home representatives.
“We have examined the policies on elder abuse in the UK which are excellent and we are usefully basing some of our ideas on these”, says Dr O’Neill. “We are at the stage now where we have set up two pilot projects, based in Kerry and Limerick. Both health boards involved have appointed elderly abuse case workers to investigate any reported incidents”.
After the group reports its findings early next year it is hoped that there will then be a public information campaign to highlight the problem of elder abuse. The campaign will be directed at the general public, rather than just healthcare professionals, for a number of reasons.
Firstly, the perpetrators of abuse are often family members who care for an elderly relative in their own home. This form of abuse is rarely detected and it is felt that highlighting the issue may help to curtail its extent. Also, relatives of older people are the best people to maintain vigilance. Families who regularly visit their elderly relatives in nursing homes and residential facilities are the most likely people to spot if anything unacceptable is going on.
So what are the tell-tale signs that an older person is being abused? According to the American National Centre of Elder Abuse, the symptoms of abuse vary with the nature of that abuse, but things to look out for include:
- Unusual or unexplained injuries, such as cuts, bruises or burns, for which strange and inconsistent explanations are given
- Unkempt appearance
- Pressure or bed sores
- Evidence of confinement, such as being tied to furniture or locked in a room
- Dehydration or malnutrition without a medical cause
- Fear, withdrawal, depression, or anxiety
- Visits to many doctors or hospitals
- A hesitation to talk openly
Sometimes when abuse is suspected, it is not clear who might be perpetrating it. In the case of an older person living with their family, any one of a number of relatives, or even friends or neighbours, could be responsible. Similarly, in a care environment, a number of carers might share responsibility for the older person. Obviously, anyone who verbally assaults, threatens or insults an older person is the most likely person to be committing any abuse that might be occurring.
However, people who express indifference or anger towards an older person, or who blame that person for their own problems, may also resort to taking out their anger on the vulnerable person in their care. People with an alcohol or drug dependency problem are more likely to be abusive and also require money on a regular basis.
What is known is that the level of elder abuse is set to rise as the proportion of senior citizens in our population increases. Though women tend to live longer, both sexes are equally at risk of being abused. The abuse can take many forms, from financial exploitation to physical assault, neglect to sexual abuse.
Abusers are often expressing their own frustrations at the weight of their caring responsibility. Older people now live longer and some carers, alone for much of the day with people who have a lot of needs, find that the responsibility can take a toll on them. This cannot excuse abuse of the vulnerable, but it may help in understanding the phenomenon.
Elder abuse is usually categorised in two ways. Domestic elder abuse is abuse that takes place in the home. It might be an older person living with offspring who spend their money without authorisation, or an elder who experiences maltreatment by a carer.
Institutional elder abuse takes place in residential facilities such as nursing homes and care facilities. Generally, it takes the form of neglect, psychological maltreatment or physical assault. However, the nursing homes subvention scandal, when widespread withholding of money from elderly people in nursing homes took place on an institutional level, can also be considered as a form of elder abuse.
Elder abuse has only been recognised as a social problem in the last couple of decades. The first reported case of elder abuse in the world was only 26 years ago, and no case of elder abuse was reported in Ireland until 1987. Dr Des O’Neill believes that the extent of the problem has not truly been acknowledged in this country.
“There is a very low awareness of the problem of elder abuse in Ireland”, he argues. “It is not unlike the situation regarding domestic violence or child abuse ten years ago. Even when people are made aware of it, they still assume that it doesn’t happen here”.
There is a consensus among experts that a wide range of abuse of older people exists. Their physical frailty and dependency on others leaves them vulnerable to a number of different forms of abuse. The media often focus on more ‘newsworthy’ cases of physical and sexual abuse of older people, but in fact financial exploitation and psychological abuse are much more widespread.
The most common form of abuse that older people face is psychological abuse at the hands of those who are responsible for caring for them. Some older people face daily threats of harm or violence, while others are regularly humiliated, intimidated or verbally abused. The victims of psychological abuse are often isolated from other contact, itself a form of abuse and have little outlet to report their experiences.
Many older people are the victims of financial abuse. In their twilight years, they may have amassed savings which are the reward for a lifetime’s work. When mobility difficulties or mental impairment requires that they hand over some responsibility for their financial affairs to others, there is always the possibility that theft, fraud or exploitation can occur.
This is not merely an issue of unscrupulous carers drawing down a person’s pension and keeping it. Older people have reported cases of property being misappropriated and pressure applied to them to change their wills. It is impossible to know how many cases of financial abuse have gone unnoticed and fear undoubtedly has led to some old people losing property or assets worth hundreds of thousands of pounds.
In the eyes of the law, there are only two forms of elder abuse – those which are criminal offences and those which are not. Obviously incidents of physical or sexual assault are crimes and ought to be reported to the police. Equally, fraud or financial exploitation is against the law. In these cases, the responsibility for initiating action rests with the State, in the form of the gardai and the Director of Public Prosecutions.
A Garda spokesperson said that there were currently no guidelines in relation to elder abuse similar to the procedures that apply to child abuse cases. Nor is there a specific classification of crime in terms of age. The Garda Commissioner’s annual report will contain statistics on reported assaults or sexual abuse and the number of subsequent prosecutions, but will not break those figures down in terms of age.
“Individual cases of elder abuse are generally dealt with at local station level by individual gardai”, the spokesperson explained. “Reports of abuse most often originate from the victims themselves, or from third parties with regular access to the victim, such as a public health nurse. If we get a report of an assault, or any crime, we will take statements and gather the evidence”.
For this reason, when cases of physical or financial abuse are suspected, it is essential to involve the gardai as a matter of course. While this often strikes people as an overreaction, it is vital to safeguard the well-being of older people in general, as Dr O’Neill explains.
“We have to ask if we are including older people as equal partners in our society and the answer is surely no. The rights of older people are being eroded or ignored all the time, as the introduction of screening for drivers over 70 years old indicates. That is discrimination and discrimination runs through our society’s attitudes to older people”, he said.
“Part of the problem is the relative weakness of the advocacy of older people and their rights. There are no less than eight different representative organisations for older people. Perhaps we should be looking at countries which genuinely look after their older people, like Denmark and America”.
Just as the abuse that older people suffer can vary so can the kind of person that abuses them. Cases like that of Michael Boyce, who was recently jailed after terrorising and raping an elderly woman for 11 years in Westmeath, are the most horrific, but strangers are very rarely responsible for elder abuse.
More commonly, the culprit is not only known to the victim, but associates with them on a regular basis and may even be responsible for caring for them. Relatives, care workers, nursing home staff and friends are all more likely to abuse an older person than the sick few who get kicks from deliberately exploiting vulnerable people.
In one sense, abuse by a stranger is easier to address. Ongoing abuse of an older person by someone in a position of responsibility or trust can be hard to detect, not least because the victim may fear recrimination or the deprivation of care if they report the abuse. They may fear being abandoned by the abuser and may not wish or be able to assist a criminal investigation.
Older people are adults. If they are mentally competent and they choose to remain in an abusive situation, their decision must be respected unless there is a criminal case to be answered. However, elder abuse can be reduced by encouraging older people to make their own decisions and to retain a degree of independence in their lives. According to Dr O’Neill, many families, with the best will in the world, often undermine their elderly relatives’ desires to retain that independence and control.
“Very often older people will choose independence ahead of risk, but this is not always properly acknowledged”, he says. “Relatives do not always understand why an older person would prefer to live at home where they might be at risk of accidents to living in a nice nursing home with lovely wallpaper where they can be monitored”.
In exerting their independence, older people reduce the possibility that they will be the victim of abuse. Yet they are often frail and vulnerable people and circumstances can place them in a situation where abuse can occur.
Older people deserve to be treated with the respect that their lives and achievements as people warrant. For that reason, it is crucial that those who live, work or socialise with the elderly maintain vigilance on the issue of abuse. Legislation may be necessary and will likely follow the recommendations to be made in the Department of Health working group’s report.
The most important change to be made, however, is in the hearts and minds of society in general. While we think of older people as burdens on the taxpayer, on the health system and on those in caring positions, we diminish their status as human beings and leave the door open for abuse to happen.
If older people are again given the respect as elders of the community that they once had, elder abuse itself might begin to be a thing of the past.
Written by Jim Clarke of irishhealth.com