Abuse of Older Persons: The Elephant in Health Care

September 2019 Blog Post written by Andrea Rochon RN, MScN

“When there’s an elephant in the room, introduce him.” – Randy Pausch

In Ontario, 20% of those 65 years of age and older have experienced or are currently experiencing some form of abuse. Think about that; 1 in every 5 older persons has experienced abuse – and these are just the cases that are reported. Despite this alarming statistic, abuse of older persons is often a hidden issue that is rarely discussed – let’s call it the elephant in health care.

The World Health Organization defines 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 does not typically occur as an isolated incident – up to 80% of cases of abuse are recurring.

Unfortunately, as people age, they may have additional vulnerabilities such as cognitive impairment and declining physical health which can render them dependent on others to assist them with basic care needs and activities of daily living. These individuals are more likely to be living with family members, caregivers, or in a care facility and may be at an increased risk for experiencing abuse. It is disconcerting to know that the abuser, or perpetrator, is often someone the older person knows and trusts.

As health care providers, we are well-positioned to support older persons who are experiencing abuse, help them to access resources, and advocate for the prevention of abuse for this population. In this blog, I will briefly describe each of the main types of abuse and what we should be considering as health care providers.

Financial Abuse
Financial abuse is the most common form of abuse of older persons. Financial abuse occurs when someone tries to take something of monetary value (e.g. money or property) from the older person or tries to control these things for their personal benefit. Family members are often the perpetrators of financial abuse as they are more likely to have access to personal information, and may be the power of attorney or have signing authority related to money and assets. As health declines and older persons become more dependent on others for assistance with instrumental activities of daily living (IADLs), the risk for financial abuse increases. While you might not see the direct health impacts of financial abuse, an older person may reveal to you that they do not have the money to pay their bills or to purchase medications. This should be cause for concern and warrant further assessment.

Physical Abuse
Physical abuse is any physical action or force that causes injury, harm, impairment, pain, or discomfort to the person. This type of abuse includes rough handling of an older person, as well as more overt physical contact such as hitting, kicking, punching, and pushing. Clinicians may be most familiar with this type of abuse because older persons are more likely to present to a health care setting to seek treatment for resulting injuries.

Sexual Abuse
Sexual abuse includes various forms of non-consensual sexual behaviours, for example inappropriate sexual comments, coercion to participate in sexual acts, sexual assault, or unwanted kissing or touching. Sexual abuse is a particularly sensitive subject when considering vulnerable older persons with cognitive impairment who have diminished judgement and capacity for consent. Older women are at high risk for sexual abuse, and should be screened accordingly.

Psychological Abuse
Psychological or emotional abuse can be verbal or non-verbal and threatens the older person’s dignity, self-worth, and emotional well-being. Examples include belittling, hurtful words, humiliating, shaming, withholding affection, or isolating the person from social contacts. Psychological abuse could also be ignoring the wishes or preferences of an older person’s goals of care. The older person may present with symptoms similar to depression: withdrawn, fearful, anxious, helpless, or tearful. Older persons with depression are at higher risk for experiencing abuse, therefore, it is important to carefully screen for both abuse and depression.

Neglect
There are also more discrete forms of abuse like neglect or abandonment. Neglect occurs when the caregiver does not meet the basic needs of the older person. Neglect can be categorized as intentional (deliberately withholding care) and unintentional (unknowingly failing to provide proper care to an older person because of lack of knowledge or resources).

Take a moment to reflect. Have you or a colleague ever used a restraint on an older person to ‘keep them safe’ or prevent a fall, or applied an incontinence product to an older person ‘just in case’ they need to go to the bathroom and you can’t make it to them on time? Have you ever witnessed a colleague or caregiver ignore concerns an older person has expressed, and instead attribute it to aging? Have you ever changed the tone of your voice when speaking with an older person, or called them ‘sweetie’ or ‘hunny’ or said ‘oh you are so cute’?

Now, pause. Think about how you would feel if someone treated you that way. If they took away your basic rights and needs, to walk freely, to go to the bathroom when you need to, to have someone listen to and address your concerns. As an adult, a professional, how would you feel if someone infantilized you every time they spoke with you? I would imagine the answer is undignified, embarrassed, belittled, and humiliated.

There is no question that we need to bring awareness and attention to the very serious physical and psychological harms that occur as a result of the more prominent forms of abuse, but we would be remise to disregard the ‘softer’ forms as abuse, such as neglect, as they are incredibly detrimental to the psychological health and well-being of older persons.

What can we do?
As health care providers there is an expectation that we will develop trusting, therapeutic relationships with our patients, and provide them with basic care needs while ensuring dignity and respect. We are instrumental in preventing, identifying, and managing abuse in older persons. The priority is always the safety of the older person. We need to be alert to risk factors and we need to be vigilant. We need to know how to approach the issues of abuse and how to have difficult conversations. We need to know what questions to ask. Familiarize yourself with local resources that are available to support older persons experiencing abuse.

Be aware that an older person who is experiencing abuse may try to hide the evidence of the abuse because they are scared, ashamed, or embarrassed. Additionally, the person likely depends on the abuser for basic care needs and assistance with ADLs/IADLs, therefore, they may worry about reprimand from the abuser, including further abuse. Provide them with a safe, open space where they feel that they can disclose and share their experiences.

Respect their values and their rights. When possible, obtain consent from the older person prior to initiating a plan of care or taking action to provide assistance and support – this, of course, is more difficult when the person is cognitively impaired, particularly if the power of attorney is also the abuser. For individuals who are cognitively intact, keep in mind that they have the right to refuse treatment.

Don’t forget about the caregivers – stress, burnout, substance use, and lack of social support increase their risk for committing elder abuse. Be proactive, ask caregivers and family how they are coping and support them in accessing resources and assistance.

Educate yourself. Make screening for abuse part of your regular assessment.

And most of all, listen to your patients, clients, residents, and older persons in the community. Listen to their stories, hear what they are not saying, give them the time to speak, don’t rush them.

Together, we can address and tame the wild elephant.