Elder Abuse

Any abuse of someone over 65 years from a relationship where there is an expectation of trust, but which causes harm or distress to the older person. May come from a carer, RACF worker/volunteer, or another RACF resident.

Can be exacerbated when carers are unsupported, or where there’s tension in the relationship as a “parent” becomes a “child. “Elderly people are much less likely to disclose abuse — fear of retribution is strong, and it’s an under-detected problem that increases the risk of injury, hospitalisation, residential placement, and premature mortality.

Prevalence

Difficult to quantify precisely — estimates range 2–14% of the elderly population across various studies. For every 1 case reported, ~5 go unreported.

Screening tools

If suspected, the Elder Abuse Suspicion Index (EASI) is a well-known 6-item tool (Q1–Q5 asked of the patient, Q6 answered by the doctor), taking 1–10 minutes:

1. Have you relied on people for any of: bathing, dressing, shopping, banking, or meals?
2. Has anyone prevented you from getting food, clothes, medication, glasses, hearing aids or medical care, or from being with people you wanted to be with?
3. Have you been upset because someone talked to you in a way that made you feel ashamed or threatened?
4. Has anyone tried to force you to sign papers or use your money against your will?
5. Has anyone made you afraid, touched you in ways you didn’t want, or hurt you physically?
6. (Doctor) Elder abuse may be associated with: poor eye contact, withdrawn demeanour, malnourishment, hygiene issues, cuts/bruises, inappropriate clothing, or medication compliance issues — did you notice any of these today or in the last 12 months?

The EASI was granted copyright by the Canadian Intellectual Property Office (2006); available at nicenet.ca.

The Vulnerability to Abuse Screening Scale (VASS) — a 17-item Australian tool — has the best local validation of any elder-abuse screening instrument and is worth using in preference to EASI where available, though EASI remains faster for a routine consultation.

Risk factors

Individual (victim): cognitive impairment, behavioural problems, psychiatric illness, functional dependency, poor health/frailty, low income or wealth, trauma or past abuse, ethnicity.

Perpetrator: caregiver burden/stress, psychiatric illness, relationship conflicts, poor social support.

Presentation

Behaviour (vague): fear of someone; irritability/worry/anxiety without clear reason; depression; changes in sleep/eating patterns; rigid posture or avoiding contact; contradictory statements unrelated to confusion; reluctance to talk openly.

Physical abuse: signs of restraint at wrists/waist; “unusual” injury patterns.

Sexual abuse: bruising on breasts/genitals/inner thighs; unexplained genital/urinary tract infections; damaged or bloody underwear; unexplained PV bleeding.

Economic abuse: unable to pay for basic care items or rent; removal of valuables from the home, or their use without consent; fraudulent behaviour or theft blamed on the patient.

Neglect: malnourishment, bedsores, overgrown nails, dirty clothing, broken or missing aids (walking frame, glasses, dentures).

Management

• Complete the EASI (or VASS) if suspected.
• Take history from the patient alone, asking direct questions to avoid ambiguity.
• Document in a matter-of-fact way.
• Seek the patient’s permission to notify police.
• Discuss with the legal guardian — or, if the guardian is the perpetrator, the appropriate advocacy source in your state.
• Consider a health-justice partnership referral — a multidisciplinary approach connecting GPs with lawyers, aged-care providers and legal services; provide information on elder-abuse helplines, specialist seniors’-rights legal centres, and public trustee offices.
• Give the national 1800 ELDERHelp (1800 353 374) line — an information/ advice service (not for immediate danger, which needs 000) that auto-redirects to the caller’s state/territory elder abuse service.