INTRODUCTION
The World Health Organization reported that it is generally agreed that abuse of older people is either an act of commission or of omission or neglect, and it may either be intentional or unintentional (Krug et al., 2002).
It results in unnecessary suffering, injury, the loss of violation of human rights, and a decreased quality of life for the older person. Like any other form of domestic violence, abuse of the elderly initially remained as a private matter hidden from public view. It was initially seen as a social welfare issue and later on a problem of ageing, but now has developed into a public health and criminal justice concern.
DEFINITIONS ELDER ABUSE
The definition of elder abused was developed by Action on Elder Abuse in United Kingdom and then adopted by the International Network for Prevention of Elder Abuse. It states that: “Elder abuse is 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” (Krug et al., 2002).
Bonnie Brandl, 2007, define elder abuse as physical, sexual, or emotional abuse; financial exploitation; neglect; or abandonment of an adult age 60 or older, who lives either in the community or a long-term care facility, perpetrated by a person in an ongoing “relationship of trust” with the victim. Self-neglect, sexual assault, theft, or financial exploitation that is committed against a long-term care facility resident by anyone, including staff, another resident, a visitor, or a stranger who enters the facility unlawfully.
FORM OF ELDER ABUSE
Physical Abuse
Physical abuse is defined as the use of physical force that may result in bodily injury, physical pain, or impairment. Physical abuse may include, but limited to, such acts of violence as striking (with or without an object), hitting, beating, pushing, shoving, shaking, slapping, kicking, pinching and burning. In addition, inappropriate use of drugs and physical restraints, force-feeding, and physical punishment of any kind also are examples of physical abuse. (NCEA, n.d.)
Sign and Symptoms of Physical Abuse Include;
*Bruises, black eyes, welts, lacerations, and rope marks
*Bone fractures, broken bones, and skull fractures *Open wounds, cut, punctures, untreated injuries in various stages of healing
*Sprains, dislocations, and internal injuries/bleeding
*Broken eyeglasses/frames, physical signs of being subjected to punishment, and sign of being restrained.
*Laboratory findings of medication overdose or under-use of prescribed drugs *An elder’s report of being hit, slapped, kicked, or mistreated
*An elder’s sudden change in behavior
*The caregiver’s refusal to allow visitors to see an elder alone
*Changes in speaking, breathing, or swallowing that may be the results of strangulation
Sexual Abuse
Sexual abuse is define as non-consensual sexual contact of any kind with an elderly person. Sexual contact with any person incapable of giving consent is also considered sexual abuse. It includes, but is not limited to, unwanted touching, and all types of sexual assault or battery, such as rape, sodomy, coerced nudity, and sexual explicit photographing.
Signs and Symptoms of Sexual Abuse Include;
*Bruises around the breasts or genital area
*Unexplained venereal disease or genital infections
*Unexplained vaginal or anal bleeding
*Torn, stained, or bloody underclothing
*An elder’s report of being sexually assaulted or raped
Psychological or Emotional Abuse
Emotional or psychological abuse is defined as the infliction of anguish, pain, or distress through verbal or nonverbal acts. Emotional or psychological abuse includes, but is not limited to, verbal assaults, insults, threats, intimidation, humiliation, and harassment. In addition, treating an older person like an infant; isolating an elderly person from his or her family, friends or regular activities; giving an older person the “silent treatment”; and enforcing social isolation.
Sign and Symptoms of Emotional/Psychological Abuse Include;
*Being emotionally upset or agitated
*Being extremely withdrawn and non communicative or non responsive
*Unusual behavior usually attributed to dementia (e.g., sucking, biting, rocking)
*An elder’s report of being verbally or emotionally mistreated
Financial or Material Exploitation
Financial or material exploitation is defined as the illegal or improper use of an elder’s funds, property, or assets. Examples include, but are not limited to, cashing an elderly person’s checks without authorization or permission; forging an older person’s signature; misusing or stealing an older person’s money or possessions; coercing or deceiving an older person into signing any document (e.g., contracts or will); and the improper use of conservator ship, guardianships, or power of attorney.
Sign and Symptoms of Financial or Material Exploitation Include;
*Sudden changes in bank account or banking practice, including an unexplained withdrawal of large sums of money by a person accompanying the elder.
*Inclusion of additional names on an elder’s banks signatures card
*Unauthorized withdrawal of funds using the elder’s ATM card.
*Abrupt changes in a will or other financial document
*Unexplained disappearance of funds or valuable possessions
*Substandard care being provided or bills unpaid despite the availability of adequate financial resources
*Discovery of an elder’s signature being forged for financial transactions or for titles of his/her possessions
*Sudden appearance of previously uninvolved relatives claiming their rights to an elder’s affairs and possessions
*Mail redirected to a new location
*New relationship in elder’s life
*Unexplained sudden transfer of assets to a family member or someone outside the family
*Provision of unnecessary services
*An elder’s report of financial exploitation
Neglect
Neglect is defined as the refusal or failure to fulfill any part of a person’s obligations or duties to an elder. Neglect may also include failure of a person who has fiduciary responsibilities to provide care for an elder (e.g., pay for necessary home care services), or the failure on the part of an in-home service provide necessary care. Neglect means the refusal or failure to provide an elderly person with such life necessities as food, water clothing, shelter, personal hygiene, medicine, comfort, personal safety, and other essentials included in an implied or agreed-upon responsibility to an elder.
Sign and Symptoms of Neglect Include;
*Dehydration, malnutrition, untreated bed sores, and poor personal hygiene
*Unattended or untreated health problems
*Hazardous or unsafe living conditions or arrangements (e.g., improper wiring, no heat, or no running water)
*Unsanitary and unclean living conditions (e.g., dirt, fleas or lice on the person, soiled bedding, fecal/urine smell, inadequate clothing)
*An elder’s report of being mistreated.
Self-Neglect
Self-neglect is defined as an adult’s inability, due to physical or mental impairment or diminished capacity, to perform essential self-care tasks including: (a) obtaining essential food, clothing, shelter, and medical care; (b) obtaining goods and services necessary to maintain physical health, mental health, emotional well-being, and general safety; and (c ) managing one’s own financial affairs. Choice of life style or living arrangements is not, in itself, evidence of self-neglect.
Sign and Symptoms of Self-Neglect Include;
*Chronic disease, cognitive impairment, mental illness, physical impairment and/or substance abuse that is often untreated
*Malnourished and/or dehydrated
*Isolated, lives alone, paranoid, often refuses access to home
*Victim appears dirty, not dressed appropriately foe the weather
*Exterior of home poorly maintained, littered with discarded items and weeds
*Stacks of unpaid bills, utilities have been shut off
*Interior of home is filled with trash, garbage, feces, urine
*Multiple animals, often in poor health or dead
*Insect or vermin infestation
*Rooting food
Abandonment
Abandonment is defined as the desertion of an older person by an individual who has assumed responsibility for providing care for an elder, or by a person with physical custody of an elder.
Sign and Symptoms of Abandonment Include;
*The desertion of an elder at a hospital, a nursing facilities, or other similar institution
*The desertion of an elder at a shopping center or other public location
*An elder’s own report of being abandoned
STATISTIC OF ELDER ABUSE
Global data
Global data Information on the magnitude of abuse in the elderly population is scanty. Since there has not been adequate awareness on the problem in most developing countries, the available information on the frequency of elderly abuse in domestic settings globally has relied on five surveys conducted in five developed countries (see Table 1).
It has been reported that the rate of abuse among older people is 4–6% if physical, psychological and financial abuse and neglect are all included (Krug et al., 2002). However, the studies were not comparable due to differences in methodologies and timeframes
Country Prevalence (%)
USA 3.2
Canada 4.0
Finland 5.4
Netherlands 5.6
United Kingdom 5.0
Source: WHO Kobe Centre, Japan 2006
In America, reported cases of elder abuse are increasing. From 1986 to 1996, there was a steady cases in reporting of domestic elder and vulnerable adult abuse nationwide, from 117000 report in 1986 to 293,000 reports in 1996. This figure represents an increase of 150.4% since 1986. In 1998, the National Elder Abuse Incidence Study (NEAIS) suggested that only the tip of the iceberg of elder abuse are being identified.
Two national studies of cases reported to Adult Protective Services (APS) in 2000 and 2004 found that during that period, there was a 19.7% increase the number of elder abuse report in all 50 states, the District of Columbia, and three territories (Bonnie Brandl …[et al], 2007)
Prevalence
According to National Research Council Panel to Review Risk and Prevalence of Elder Abuse and Neglect, Washington, DC. 2003, the best available estimates is between 1 and 2 million Americans age 65 or older have been injured, exploited, or otherwise mistreated by someone on whom they depended for care or protection.
Incidence
In 2003, state Long Term Care Ombudsman programs nationally investigated 20,673 complaints of abuse, gross neglect, and exploitation on behalf of nursing home and board and care residents. Among seven types of abuse categories, physical abuse was the most common type reported.
Survey In Japan
One research in Japan was conducted to subjects were 60 years of age or older and were all residents of an agricultural village near a large urban center on the main island of Japan. Two different surveys designed for qualitative and quantitative analyses, were conducted. Survey I was a mail survey of 3600 ‘healthy people’, to get a clear picture of what the families were like in the village and peoples’ perceptions of elder caregiver. Survey II was a home visit survey of all the frail elderly in the community ( n = 78), to identify the prevalence of elder abuse and risk factors. Survey II found that 14 elders were being abused (emotional abuse 7, neglect 6, physical abuse 3, substance abuse 3) giving a prevalence rate of 17.9% ( Anme, Tokie, 2004).
National data
In Malaysia, information and data on elderly abuse is scarce. At present, no agency keeps proper records of the incidence of elder abuse in the country. The only available data comes from the Department of Social Welfare on the number of older people living in institutions. Figure 1 shows the number of people aged 60 and above admitted to institutions from 2000 to 2005.
Regarding gender distribution, it was reported that, of the cases admitted from 2000–2005, about two-thirds of them were males. However, there could be a possible bias in the data. The higher proportion of males admitted to the institutions could also be due to the fact that elderly males have more difficulty in caring for themselves compared to elderly females.
DYNAMICS OF ELDER ABUSE
Why Does Elder Abuse Occur?
A variety of hypothesis have been explored to explain elder abuse such as;
1) Caregiver stress/excessive demands
2) Victim characteristics
3) Perpetrator characteristics
4) Transgenerational issues
5) Social exchange theory
6) Power and control dynamic
Caregiver stress/excessive demands
Most caregiver are compassionate and provide good support and care; however, caregiver ca be hard work and, at times, stressful. The caregiver stress theory suggest that overwhelmed caregivers, burdened by the demands of providing care, may at times harm the older, frail person in their care.
Victim characteristics
Some researchers have look for victim characteristics or behaviors that may have led to abusive behavior. The tendency in the past was to consider elders as dependent, vulnerable, and in need of protection. Blaming the victim was very much a part of the original (but flawed) construction of elder abuse as a manifestation of caregiver stress. This characterization, buttressed by societal prejudice against the aged and aging, had the effect of making old people into “legitimate or deserving” victims. (Wolf, 2000).
Perpetrator characteristics
A few study have examined common traits among abusers of elders. Some found that a significant number of abusers suffer some form of impairment include substance abuse, mental illness and depression, and cognitive impairment. Research also indicated that abusers tended to be dependent on their victim for housing, transportation, financial dependency, and sometimes for care. Some research also suggest that abusers have problem with relationships, may be more isolated, and lack social supports. Brown (1989) suggests that abuser with personal problems may be more physically abusive.
Transgenerational issues
This theory postulates that adults who were abused as children may retaliate against their aging parents. These interactions are a pattern of learned behaviors that teach an abused child to become an abusive parent. Another aspect of this theory is that the abuse is committed for revenge in retaliation for actual or perceived childhood abuse by elderly relative.
Social Exchange Theory
According to Pillemer (1986), social exchange theory helps to explain child abuse, domestic violence, and elder abuse. The victim is dependent on the aggressor for care (rewards). The aggressor believes that the victim is not reciprocating with equal rewards. The abuser has control of the rewards, and there are no consequences for his abusive behavior (punishment). The abuser believes that the personal rewards he derives from the exchange are too little when compare to what he is giving the victim, and therefore, he is entitled to impose punishment on the victim.
Power and Control Dynamics
Some studies have found that family violence in later life often involves an abuser who uses a pattern of coercive acts to control, dominate, or punish the victim. When abusers believe they are entitled to “run the show”, they will use any means necessary to get their needs met. Abuser feel their actions are justified and they deserve unquestioned obedience from the victim (Schecter, 1987).
Why Does An Older Person Who Is Being Harmed Maintain A Relationship With The Abuser?
· Have a relationship of trust with their abuser
· Wants to maintain a relationship with the abuser
· Still love the family member abuser and may have valid reason for trying to preserve the relationship or protect the person.
· May have value the longevity of the relationship especially spouses or life partner who have been together for many years.
· Fear to being alone.
· The victim appreciate some qualities of the caregiver or sympathize with them.
· Financial realities impact
· Cultural norm such as negative stigma to a women who lives alone or who goes to nursing homes
· Fear deportation among immigrants
· Religious values e.g. some older people believe that their religious teachings mandate that they stay in their abusive marriage.
· Health problems or the victim – require ongoing care. Staying with an abuser may seem a more inviting option than asking stranger to provide care or moving to an institution.
· Health problem of the abuser
· Living in facilities an no other choice to care of the victim.
IDENTIFICATION AND REPORTING ELDER ABUSE
Who can identify elder abuse?
*Anyone with close and regular contact with an older person
*Physicians
*Public Health Officers
*Health care provider
*Family members Friends
*Dentists
*Beauticians
*Mental Health Professional
*Professional from the faith community or aging services
*Bank personnel
*Attorneys
*Neighbor
*Mail carriers and utilities personnel
Reporting/Referring Elder Abuse
· In life-threatening situations or other emergencies – call 999
· In no threatening situations – reports can be made directly to law enforcement
· Report can also be made to social service department.
· Contacting to One Stop Crisis Center (OSCC) in the local hospital
COLLABORATIVE APPROCHES TO ELDER ABUSE
A comprehensive intervention generally focuses on :-
1. Safety
2. Health
3. Functional status including capacity
4. Legal status
5. Financial situation, and
6. Social situations
Multidisciplinary Approach
Numerous systems and agencies investigate allegations of elder abuse and provide support and services for older victims. After an elder abuse, exploitation, or neglect report or referral is made, one or more agencies may work with an individual victim and/or perpetrator such as :-
· Law Enforcement
· Domestic Violence Advocate
· Geriatrician
· Adult Protective Services
· Prosecutor
· Social Worker
· Nurse
· Home Health Aide
· Nutritionist
· Mental Health Professionals
· Local and State Regulatory Agencies
IMPACT OF ELDER ABUSE
Health impact
The fact that older people are physically weaker and more vulnerable than younger adults means that the impact of abuse on them can be more serious. The complication of injury such as delayed healing and permanent damage are more likely to occur. Regarding psychological impact, the World Health Organization has reported that several studies in developed countries show that a higher proportion of victims of elder abuse suffer from depression and psychological distress (Krug et al., 2002).
Economic impact
At present, information on the economic impact of elder abuse is very hard to come
by. There has been no research reported on the assessment of financial losses resulting from elder abuse in Malaysia. Information on the causes of financial loss subsequent to the abuse of the elder people from other countries is also lacking.
CONCLUSION
Violence and abuse is preventable. Each of us, as individuals, family members, in the community, as a society, government or nongovernmental agencies, must be play our role, hand in hand to curb this problem. Understanding the magnitude of the problem, knowing and acting against its root causes will help to provide a healthier and safer society in this country and all over the world.
REFERENCES
Anme, Tokie, 2004, A study of elder abuse and risk factor in Japanese families: Focused on the Social Affiliation, Geriatrics and Gerontology International 2004; 4: S262–S263
Brandl, Bonnie … [et al.] 2007, Elder Abuse detection and intervention : a collaborative approach, Springer Publishing Company, New York
Brown, A. 1989. A survey on elder abuse at one Native American tribe. Journal of Elder Abuse & Neglect, 1 (2), 17-37
Jabatan Kebajikan Masyarakat Malaysia (2006). Profil Statistik Jabatan Kebajikan Masyarakat Malaysia 2005.
Krug EG, Dahlberg LL, Mercy JA, Swig AB and Lazano R (eds). 2002, World Report on Violence and Health,. World Health Organization (WHO), Geneva
McInnis-Dittrich, Kathleen, 2005, Social Work with elders : A Biopsychosocial Approach To Assessment And Intervention, Pearson Education, Inc., Boston
National Research Council Panel to Review Risk and Prevalence of Elder Abuse and Neglect. Washington, DC: Elder Mistreatment: Abuse, Neglect and Exploitation in an Aging America. 2003.
National Ombudsman Reporting System Data Tables. 2003. Washington, DC: U.S. Administration on Aging
Pillemer, K. 1986. Risk Factors In Elder Abuse: Results From A Case Control Study. In K. A. Pillemer & R.S. Wolf (Eds.), Elder Abuse: Conflic in the family (pp. 239-263), Dover, MA: Auburn House
Report National Report On Violence And Health Malaysia, World Health Organization Centre For Health Development Kobe, Japan, WHO Kobe Centre, 2006
Schechter, S, 1987, Guidelines for mental health practitioners in domestic violence cases, Denver: National Coalition Against Domestic Violence.
Turner, Francis J., 1995, Differential diagnosis and social work, 4th ed., The Free Press, New York
Wolf, R.S. 2000, Introduction: The nature and scope of elder abuse. Generation, 24 (2), 6-12
