Elder abuse

Two incidents last week brought elder abuse into the public eye: a community trust in London reported that three staff had been sacked (and others disciplined) for physically abusing the elderly people in one of their homes, Beech House, and Lucille McLauchlan, the nurse imprisoned in Saudi Arabia for murder, was convicted of stealing money from a 79 year old patient when she was a nurse in Dundee. The mistreatment at Beech House included slapping, cold baths, verbal threats, intimidation, withholding drinks, and tying patients up. No one doubts that elderly people can be abused by their carers, but despite a series of high profile cases over the past 30 years,¹,² elder abuse is not widely accepted as a social or medical problem.

The Beech House inquiry exposed ignorance, denial, poor management, low morale, and inadequate training—a litany that defines any poor quality enterprise. These failures still occur because the messages from repeated institutional scandals are ignored. As well as physical abuse (including murder), other forms include sexual abuse and—probably even more prevalent—verbal, financial, and psychological abuse of elderly people at home. Twenty years after Burston first described “granny battering”³ we have yet to tackle the issue with the same vigour as we have tackled child abuse and domestic violence. What then should health professionals and policy makers be doing?

Firstly, good information is needed, because without it there will be poor political support for spending on intervention. Most studies have looked at elder abuse at home, not in institutions, and most are from America. On both sides of the Atlantic community surveys suggest that verbal abuse is common at home,⁴,⁵ and 0.5-2% of elderly people have probably experienced physical abuse.⁴,⁵,⁶ The true prevalence of financial abuse is unknown, and reliable data on abuse in hospitals and nursing homes in Europe are almost non-existent. In one American survey of 577 nursing home staff a tenth admitted physically abusing their clients, and 40% admitted to psychological abuse.⁷

Secondly, all health professionals who deal with elderly people should be trained to detect and manage suspected abuse. The factors involved when carers abuse are complex. Picking up warning signals and intervening effectively require sensitivity and skill. Surveys suggest that general practitioners, who are ideally placed to diagnose abuse, feel poorly prepared,⁸ probably because interpersonal violence is all but ignored in medical education.⁹ Even banks and building societies should be teaching their staff to recognise when someone’s assets are being misappropriated.

The charity Action on Elder Abuse has made a start by producing guidance on how to detect, report, and manage abuse.¹⁰ This advises on how to approach victims and abusers, but most importantly emphasises action. The pamphlet for doctors says “You must always act if you come across abuse or you have strong suspicions that it is happening.... You do not have to prove that abuse has taken place, only that you have reasonable cause to suspect it.” Readers are referred to local protocols for advice, although in 1995 only a fifth of trusts and a quarter of health authorities surveyed had policies.¹¹

Even if doctors were familiar with the problem, diagnosed it readily, and could rely on local policies to tell them what to do, invoking the law to protect someone in the United Kingdom is complicated. Action on Elder Abuse gives advice on this too, but busy health workers need more than a few bullet points to guide them through the dozens of potentially relevant acts, including the Family Law Act 1996, the National Health Service and Community Care Act 1990, the Mental Health Act 1993, and the National Assistance Act 1948. By contrast, every state in America has adult protection laws tailor made for older people. Forty three states have even made reporting suspected abuse compulsory, although critics, including the Law Commission in Britain, say mandatory reporting is unworkable.¹²

The Law Commission, responding to a broad consensus that the existing legislation is inadequate, has recommended new protection laws including extending the power of local authorities to enter premises, remove vulnerable adults to a place of safety, and protect their property and assets. The commission’s proposals are included in the 1997 green paper on mental capacity Who Decides?,¹³ which is currently being held up by the government’s ambitious legislative programme.

The problem of elder abuse may get worse as the number of elderly people increases around the world. It would be a grim irony if the extraordinary increase in life expectancy that has occurred in this century simply delivered a large cohort of unprotected and vulnerable people to be abused in the next.