In honour of World Elder Abuse Day on June 15, 2011 this month's Elder Voice focuses on elder abuse and neglect.

Elder abuse is willful, intentional action that causes emotional physical, financial or sexual harm to an elderly person. It's purpose is power or gain--either financial or emotional--on the part of the abuser. Lack of action or attention leading to harm constitutes neglect.

Although Statistics Canada cites a 7% reported rate of emotional or financial abuse in 2007, when all types of abuse are considered clearly rates have been much higher. According to the American Psychological Association, there are more than 2 million cases of elder abuse reported each year in the U.S., and as many as five cases that go unreported for each reported case. Actual levels of abuse will most likely never be known because it is often not discovered or reported. The most frequent place of occurrence is not, as many may think, in a nursing home. Rather it is a private place of residence, and the perpetrator is most likely to be a family member,friend, or paid caregiver.

The range of behaviours that constitute abuse and neglect are wide. Physical abuse is pushing, shoving slapping, and even the rough treatment that occurs when a caregiver is in a hurry. Emotional abuse includes name calling, humiliating, yelling,and threatening an older person. Financial abuse includes taking money or possessions for one's own use when not authorized to do so and refusal to purchase care and services which would improve or maintain lifestyle and for which an individual has the funds. Neglect includes behaviours such as not changing, bathing,helping to the toilet, or not providing adequate nutrition to a dependent senior.

Another form of abuse seen most often in care facilities is the use of physical restraints or medication to control behaviour for reasons other than the safety or health. Restraints should never be used in place of adequate and through problem solving or for the convenience of staff. At the same time, medication or restraints can be the most appropriate response to a resident's needs. Each situation needs to be assessed, overseen, and reviewed regularly.

People who would not have been targets for abuse when they were younger can become so as they age for many reasons. Physical frailty and cognitive impairment put them in situations in which they are dependent on others. Cognitive impairment also impacts on their judgment and insight, making it more difficult for them to protect themselves or recognize when they are being taken advantage of. Isolation due to loss of a spouse or friends, reduced mobility, and hearing or vision loss can also reduce their ability to seek help or reduce the likelihood that abuse or neglect will be discovered.

Abusive or neglectful behaviour which is not meant to be malicious also occurs. Reasons for this include the following:

1. Burnout: Caregivers who are isolated, feeling helpless, hopeless or depressed, and burned out can react with anger when they might not due so under "normal" circumstances. When they do not know what to do, how to handle a situation, or are themselves hit or yelled at by an impaired person they may react with threats, by use of restraints, or hitting.
2. Lack of Knowledge: Caregivers may become abusive when they do not understand the reason for a behaviour. For example, an elderly spouse may not understand that his wife's behaviour is caused by Alzheimer's disease destroying her insight and judgment and not something she is able to stop. A wife may not understand that her husband's anger is the result of stroke related dementia. An adult son will try to reason with his father, thinking if he only explains it again and again somehow the parent will understand; when he doesn't the son starts to yell.
3. Shame: Abusive or neglectful behaviour can occur when a caregiver is too ashamed to ask for or accept help. A husband may not wish to burden his adult children about the stress of caring for his wife. He may feel that he is a failure for not being able to care for her, or that it is a sign of weakness.
4. Caregiver impairment: Neglect can occur when a husband or wife does not seek help because they themselves are cognitively impaired and do not have the capacity to provide the care their spouse requires.
5. Guilt: Caregivers may have promised never to put someone in a nursing home and believe it is their responsibility to provide care. They end up feeling resentful and angry when they don't want or can no longer do so. They feel guilty about the anger and resentment, and the guilt and anger build and feed off each other until abuse or neglect occurs.

While we may never be able to completely stem the occurrence of abuse or neglect, we can act so that the incidence and risk are lowered. Below are some ways to help:

1. Caregivers need support and social connections so that they do not become isolated and overburdened.
2. Family members need to be targeted for education and intervention by medical systems as soon as a loved on is diagnosed with any kind of disease which will lead to long term caregiving.
3. A simple questionnaire that would identify caregivers who are at risk for for abusing or neglecting should be administered at time of diagnosis of a disease such as Alzheimers. It would ask about social connections, financial stresses, depression,physical illness, family situation and other known risk factors. When identified, people at risk can be followed more closely
4. Respite needs to be available to caregivers in a form which they will use.
5. Individuals without close family or friends, and whose estates and/or funds are being managed by trust companies, banks, or the public trustee should have a professional care manager to monitor their care and home situations.
6. Physicians with patients who require caregiving from family members or others, or with patients who are caregivers, need to be aware of the situation and monitor stress levels on an ongoing basis and be mindful of potential abuse. This needs to be supported by the fee structure of provincial health programmes.
7. Outreach such as phone calls and volunteer visitors need to be available from communities and health authorities.
8. In the legal arena, laws need to be strengthened so that vulnerable adults are protected more easily
9. Specialized teams should be developed and made available to assess and intervene with vulnerable adults and at-risk caregivers.
10. Companies and charities need to review their policies so that they are not targeting vulnerable seniors for donations. "Do not call" legislation needs to be amended so that seniors can opt out from being called by charities or other companies for any reason.

When caregivers receive intervention, they are often horrified at what they have done, or how they have reacted, and be too ashamed to seek help. Whereas abusive behaviour and neglect are never acceptable, we can help people to understand and take care of themselves and seek help when they need it.

Anyone who suspects that abuse of an elderly person is occurring should either call the police, adult protective services, the public trustee, or provincial or local health authorities.

For more information about Elder abuse and neglect, please see the following:

The American Psychological Association

The Help Guide

Elder Voice July 2008 (Financial vulnerability of Seniors)

B.C. Centre for Elder Advocacy Support

Below are signs that indicate a person may be being abused or neglected. Be aware that these may have causes unrelated to abuse or neglect. Confusion or fear, for example can be the result of dementia, overmedication, and delirium as well as abuse. Black and blue marks may be the result of naturally occuring bruises or light touching on skin that is fragile. Falls happen in the best of care facilities, no matter how careful or well trained staff may be. Money may be missing because someone has hidden it and does not remember doing so or where they hid it.

Physical or Emotional Abuse:

• Unexplained bruises or injuries, or injuries that occur only at certain times or in certain places
• Fear or anxiety of specific people or places
• Incontinence
• Confusion or timidity, or unexplainable changes in behaviour
• Broken or damaged equipment and sensory aides.
• Difficulty in making decisions
• Fear of being alone
• Depression and/or generalized anxiety
• Oversedation
• Changes in relationship with family or friends
• Checking with a caregiver or family member before speaking or changing what is said depending on who is in the room.

Neglect:

• The person has an odour about them, appears dirty
• Clothes are ill fitting, old, in poor condition
• Signs of incontinence
• Residence is dirty or in poor repair
• Medication is not being taken
• Recurring infections or disease
• Weight loss, malnutrition, dehydration
• Depression and/or anxiety

Financial Abuse:

• Unexplainable withdrawals of money from accounts
• Ongoing purchases that are not of benefit to the individual or are uncharacteristic for that individual
• Needs for clothing, housing, medications are ignored
• Presence of new friends in someone's life
  Changes in legal documents such as power of attorney, will, or representation agreements.
• Missing money or valuables

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