Elder abuse or family violence
Definition and types
- Single or repeated act, or lack of appropriate action, within a relationship of trust, causing harm or distress to an older person (WHO definition)
- Types: physical, psychological/emotional, financial, sexual, neglect (act or omission), social/civic restriction
- Financial abuse is the commonest type reported in Australia; physical and psychological abuse frequently coexist
Prevalence
- ~1 in 6 (≈15%) of people >=60 experience some form of abuse annually (WHO/national prevalence estimates)
- Perpetrator is usually a family member - adult child commonest, followed by spouse/partner
- Markedly under-detected and under-reported - most cases never disclosed
- Risk higher with cognitive impairment, functional dependence, social isolation, and cohabitation with the perpetrator
Victim-related risk factors
- Cognitive impairment/dementia, functional dependence, frailty
- Social isolation, lack of alternative supports
- Prior history of family violence, communication difficulty
Perpetrator-related risk factors
- Carer stress/burnout, financial dependence on the older person
- Perpetrator mental illness, substance misuse
- History of family conflict or violence, cohabitation
Systemic factors
Systemic
- Ageism, lack of routine screening, financial/legal complexity (enduring power of attorney misuse)
Suspicion - clinicians must actively look
A. Suspicion - clinicians must actively look
- Injuries inconsistent with the stated mechanism, or delayed presentation
- Unexplained weight loss, dehydration, pressure injuries, poor hygiene (neglect)
- Unusual financial patterns - missed bills despite adequate funds, sudden changes to will/EPOA, unexplained withdrawals
- Fearful, withdrawn, or contradictory affect in front of a carer; carer answering all questions
- Medication non-adherence not explained by cognition alone
Assessment
B. Assessment
- Interview the patient alone - essential, non-negotiable step
- Direct, non-judgemental screening questions (e.g. "Do you feel safe at home?", "Has anyone hurt you or taken things without permission?")
- Assess decision-making capacity - abuse and impaired capacity often coexist and each complicates the other
- Document findings objectively and contemporaneously (may be needed for legal proceedings)
- Involve social work, geriatrician, and where relevant, Aged Care Assessment Team
No diagnostic test
C. Note there is no validated diagnostic "test" - this is a clinical/psychosocial diagnosis built from history, examination and collateral information, cross-checked for inconsistency
Immediate safety
A. Immediate safety
- Assess immediate risk - if life-threatening, treat as an emergency (admission may itself provide a place of safety)
- No universal mandatory reporting law for elder abuse in Australia (unlike child protection) - but mandatory reporting applies in Commonwealth-funded residential aged care for reportable assaults
- Respect the person's autonomy and wishes if they have capacity - do not override a competent adult's choice to remain in the situation, but document and offer ongoing support
Where capacity is impaired
B. Where capacity is impaired
- Statutory guardianship/administration referral if decision-making is compromised and abuse ongoing
- Involve public advocate/public trustee for financial abuse with incapacity
Multidisciplinary and system supports
C. Multidisciplinary and system supports
- Social work central to every case - safety planning, supports, respite for carer stress cases
- 1800 ELDERHelp (national elder abuse phone line) for information and referral
- Police involvement for criminal acts (assault, sexual abuse, fraud) with patient consent (or without, if immediate danger/legal duty)
- Carer support/respite where carer stress is a driving factor - addressing this can resolve neglect without removing the older person from their home
- Legal review of enduring power of attorney/guardianship documents if financial abuse suspected
Follow-up
D. Follow-up
- Ongoing review - abuse is often iterative rather than resolved in one encounter
- Safety planning and a clear route for the patient to seek help without the abuser present
Associations
- Dementia and cognitive impairment
- Functional dependence and frailty
- Social isolation
- Carer stress and carer mental illness/substance misuse
- Impaired decision-making capacity
- Financial dependency of carer on victim
Consequences
- Associated with increased mortality independent of the physical injuries sustained
- Progressive functional and psychological decline if unaddressed
- Physical injury, malnutrition/dehydration (neglect), depression, PTSD-type symptoms
- Financial abuse can leave the person without means for future care
- Often escalates without intervention; recognition and multidisciplinary support improve outcomes but ongoing monitoring is usually required
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