Overview
The WHO 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”.
Safeguarding is defined as the protection of a person’s health, wellbeing, and right to live in safety, free from harm, abuse, and neglect.
An adult at risk is defined as a person aged 18 years or older who:
- Has care and support needs
- Is experiencing/at risk of abuse and/or neglect
- Is unable to protect themselves because of their care and support needs
Epidemiology
- Seen more in people with physical/mental disabilities, learning disabilities, and substance misuse
- The prevalence increased by around 10 times during the COVID-19 pandemic
Risk Factors
- Cognitive impairment
- Older age – patients may be more frail or less able to be independent
- Social isolation
- Dependence on a carer
- Previous history of abuse
- Mental illness in the carer – e.g. depression
- Negative experiences of disclosing abuse
- Substance abuse by the older person/carer
- Lack of access to social and health services
- Financial dependence of the carer on the older adult
Types of Abuse
There are 10 types of abuse in the Care Act (2014):
- Physical abuse:
- E.g. violence, inappropriate restraint, misuse of medication
- Sexual abuse
- Psychological abuse
- E.g. emotional abuse, threatening harm/abandonment, deprivation of contact, blaming, humiliating, intimidation, controlling, harassment, verbal abuse
- Financial/material abuse:
- Theft, fraud, exploitation, pressuring during will-writing, abuse regarding property/inheritance/finances/possessions/benefits etc.
- Neglect and acts of omission:
- Ignoring medical or physical needs, failing to provide access to health care/social care/educational services, withholding medications, not providing adequate nutrition or heating etc.
- Discriminatory abuse:
- Racism, sexism, and abuse based on the person’s disability
- Domestic abuse:
- Psychological, physical, emotional, sexual, financial, “honour-based violence”
- Modern slavery:
- Slavery, forced labour, trafficking
- Organisational abuse:
- Neglect and poor caregiving within an institution or care setting e.g. hospice or care home
- Self-neglect:
- Neglecting hygiene, health, surroundings, behaviours such as hoarding
Example History
An 85-year-old woman who lives with her daughter is brought to the GP. She has Alzheimer’s dementia and was hospitalised for a fall 3 months ago. During the consultation, her daughter appears tired, and frustrated and repeatedly contradicts what her mother ways. She refuses to let her mother be spoken to by herself. On examination, her mother has multiple bruises of different ages on her left arm.
Confidentiality
If the person has capacity under the Mental Capacity Act (2005), then doctors have no legal authority to make best-interest decisions on their behalf.
People need to be informed that there may be circumstances where information may be shared if there is a risk of significant harm to others and in cases where it is in the public’s best interest.
If someone discloses abuse or neglect, do not agree to keep secrets or make promises you cannot keep.
Presentation
If you suspect abuse or neglect, you must act on it. Do not assume that someone else will.
When addressing potential abuse:
- Make sure the abuser is not present
- Be clear with what will happen with the information the victim discloses
- Establish the facts of the abuse and acknowledge the impact it has on the victim
- Ensure the person has support expressing themselves, including an interpreter if needed
- It may help the abused person to have a trusted person with them
Sometimes the victim may:
- Seem withdrawn
- Have unexplained fear
- Fail to make eye contact
- Be agitated
- Behave in a way that is not appropriate for the level of dementia or depression they have e.g. infantile behaviour
Sometimes direct questions being asked may help:
- Who’s at home?
- Are you happy at home?
- Are you sleeping?
- How are you eating?
- Has anyone ever touched you without your consent?
- Has anyone ever made you do something you didn’t want to do?
- Has anyone ever taken something that was yours without asking?
- Has anyone ever hurt you?
- Has anyone ever scolded or threatened you?
- Have you ever signed any documents you didn’t understand?
- Are you afraid of anyone at home?
- Are you alone a lot?
- Has anyone ever failed to help you take care of yourself when you needed help?
If the carer to refuses to let the patient answer any of the questions themselves, or refuses to let you speak to them alone, this may suggest abuse.
If abuse is suspected, patients should be examined thoroughly. Any injuries must be documented and photographed. Examination may show:
- Unexplained injuries
- Injuries inconsistent with the history
- Contradictory explanations given by the patient and carer
- Bruises, lacerations, rope marks, burns, welts
- STIs or genital infections
- Dehydration, malnutrition, pressure sores, poor hygiene
Inconsistencies between the history and physical examination, medications the patient takes, investigation results, or living conditions may suggest abuse.
The risk to people other than the patient should also be considered e.g. other vulnerable adults present, children etc.
Management
- If a life is in immediate danger or there is a significant risk of serious harm, ring 999.
- If risk of significant abuse, all cases should be referred to the local safeguarding team.
Patient Advice
- Patients who are deemed to have capacity that do not want immediate action being taken (provided there’s no risk to their life or danger to others, and that reporting does not affect the public’s best interests) should be given clear instructions on who to call and what resources are available to them in emergencies.
