Elder Abuse and Palliative care: The time to act is now!

Elder Abuse and Palliative care: The time to act is now!

– Dr. Anish S, Thrissur

Every year June 15^th is observed as World Elder Abuse Awareness Day (WEAAD) by the United Nations General Assembly. The day aims to provide an opportunity for communities around the world to promote a better understanding of abuse and neglect of older persons by raising awareness of the cultural, social, economic and demographic processes affecting elder abuse and neglect.

What is elder abuse?

The United Nations 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/senior person”. Elder abuse can have serious consequences on a person’s physical and mental health, financial, and social well being. The impact could manifest by ways of physical injuries, premature mortality, depression, cognitive decline, financial devastation, and in the placement of the older adult in nursing homes / old age homes.

Estimates indicate that elder abuse affects one in six older adults worldwide, which is an approx. of 141 million people. Actual figures may however be much higher due to underreporting. According to Longitudinal Ageing Study in India (LASI), at least five per cent of India’s elderly population (aged 60 years and above) stated they experienced ill-treatment in 2020.

Elder abuse is therefore a neglected global public health priority, in comparison to other types of violence.

Elder abuse most often tends to occur mostly at home by known family members – children, son/daughter in law, a spouse or a caregiver. Sometimes, abuse can also take place in institutional settings such as long term care facilities and nursing homes, and are perpetrated by health care workers.

Why is elder abuse under-reported?

The under reporting of elder abuse, both in India and globally, is due to a host of factors some of which includes

• Denial by both the elderly person and the perpetrator
• The clinicians’ reluctance to report victims
• The disbelief by the clinician’s or the health care providers
• The clinicians’ lack of awareness to recognise warning signs
• The social and financial dependence of the elderly person on the perpetrator

Elder abuse and Palliative care

Elder abuse can be in the form of physical, psychological, financial, sexual abuse or even simply in the form of neglect by failing to provide for medicines, food, clothes etc. Older adults receiving palliative care usually have high levels of dependency on their caregivers. A combination of caregiver stress and victim dependency increases the risk of abuse. The burden of elder abuse in palliative care remains under recognised due to the paucity of studies in this area of concern.

Abusive family relationships deter and pose as a hindrance to delivering holistic and quality palliative care.

The Home visits by the palliative care team creates a golden opportunity for health care providers to screen for elder abuse, as the volunteers and health care providers may sometimes be the only people who visit the older adult, beyond their immediate family.

These health care providers need to establish and foster positive relationships with the older adult to accurately identify signs of abuse in a timely manner.

Older adults should be screened by the health worker, preferably in the absence of the caregivers with questions such as,

• “Do you ever feel unsafe where you live?”
• “Has anyone ever threatened or hurt you?”
• “Has anyone been taking your money without your permission?”
• “Does your caregiver ever yell or curse at you?”
• “Have you been threatened with being put into a nursing home / old age?”
• “Are you ever prevented from seeing friends and family members whom you wish to see?” etc.

Some of the cues for possible elder abuse involves observing the behavior of the older adult and the behavior of the caregiver.

Cues for elder abuse on the basis of the behavior of the older adult, includes:

• Older adults seems to be afraid of the family / caregiver
• Behaviour changes when caregiver exits the room
• Displays of exaggerated respect or extreme deference towards the family / caregiver

Cues for elder abuse on the basis of the behavior of the caregiver, includes:

• The caregiver hinders or prevents you from talking with the older adult in private
• The caregiver’s insistence to answer questions addressed to the older adult
• Attempts by the caregiver to convince you that the older adult is ‘crazy’ or ‘demented’

It is important to also keep a check on the signs for physical abuse by checking for Injuries that don’t match the explanation given, the presence of multiple injuries at different stages of healing, and for Injuries and wounds in concealed places.

It therefore becomes absolutely critical to sensitise, train and empower palliative care providers to recognize and identify elder abuse. This one single step forward is guaranteed to take us a long way towards the early detection and taking of prompt action in cases where there is elderly abuse.

How can we, as palliative care professionals prevent elder abuse?

• Organising public and professional awareness campaigns
• Organising school-based inter-generational programmes
• Organising Money management/ finance management programmes for older adults
• Creating older adult social / support groups
• Being empowered to screen for elder abuse
• Providing caregiver support intervention programs such as stress management sessions, respite care etc.
• Training the caregiver on effectively managing patients with dementia

How to report elder abuse?

The Ministry of Social Justice and Empowerment, Government of India, has set up ‘Elder Line 14567’, a pan-India toll free helpline for senior citizens to report elder abuse. This service is open seven days a week from 8 a.m. to 8 p.m. A written complaint can also be filed in the jurisdictional police station. In the case of an assault, a First Investigation Report (FIR) can be filed by the victim themselves.

Health care professionals have an ethical and legal responsibility to report and work towards preventing suspected abuse.

Let us therefore keep our eyes and ears open, to tackle this underreported menace and improve the quality of life of our senior citizens, and eventually, our own  too….

Take Home Messages

• Elder abuse is under reported and often unsuspected
• Older adults have an increased risk of elder abuse due to their high dependency on caregivers
• Training of palliative care providers on how to screen and identify elder abuse is key to providing quality palliative care for this vulnerable segment of the population
• Call ‘Elder Line 14567’ for assistance in case of elder abuse

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For further reading:

1. Jayawardena KM, Liao S. Elder abuse at end of life. J Palliat Med. 2006 Feb;9(1):127-36. doi: 10.1089/jpm.2006.9.127. PMID: 16430352.
2. Levine JM. Elder neglect and abuse. A primer for primary care physicians. Geriatrics. 2003 Oct;58(10):37-40, 42-4. PMID: 14569641.
3. Fisher, Colleen. (2003). The Invisible Dimension: Abuse in Palliative Care Families. Journal of palliative medicine. 6. 257-64. 10.1089/109662103764978515
4. Yon Y, Mikton CR, Gassoumis ZD, Wilber KH. Elder abuse prevalence in community settings: a systematic review and meta-analysis. Lancet Glob Health. 2017 Feb;5(2):e147-e156. doi: 10.1016/S2214-109X(17)30006-2. PMID: 28104184