A typical case of the elderly domestic violence in Finland

Objectives

1. To illustrate the family dynamics in a case of elder abuse.
2. To show how financial problems and alcohol abuse by the caregiver can trigger abuse, one of the more common forms of elder abuse
3. To illustrate the value of a multidisciplinary team in the assessment and care of an abused person.

Narrative case:

A 79 year old woman, living with her son in a 2-room apartment, came to the day clinic [1]. The patient said that she fell over her rollator and bruised herself the previous evening. She had difficulties breathing, pain all over her body and was sad, shaking, meanwhile making no eye contact during talking [2]. She started to cry on a number of occasions during the conversation and examination. The doctor, a specialist in geriatric medicine, examined the patient and was surprised by the number of bruises and hematomas on her body and left cheek and orbit, where later a fracture of the cheek bone was diagnosed. There were also some bruises on both forearms. On x-ray examination, multiple old rib fractures were found. From previous documentation it was found she was examined earlier due to a falling problem, with no orthostatic reaction and she did not appear to be using prescribed  blood pressure lowering drugs. The patient denied alcohol consumption. Domestic violence is suspected by the examining doctor.

During treatment, the patient was found to be suffering from malnutrition and weighed only 45 kg with a plasma albumin well below normal. She refused to eat and expressed wishes of wanting to die [3]. Her cognitive status was defined by tests as mild cognitive impairment [4]. When carefully asked about what happened on the night prior to hospital admission, she confirmed that her son abused her and he had come home drunk late at night. She says that the relationship with her 49 year old son had deteriorated lately due to his alcoholism. Her son is often out of the house. He has been unemployed [5] for quite some time and threateningly demanded that she shared her small pension with him. Lately, the patient had on a number of occasions refused to give her money away because she was afraid [6] her son would simply drink more. Whilst telling this fact,the patient started to cry bitterly. Later in conversation, it came out that for about two years her son physically abused his mother regularly.

This case was discussed by a team, consisting of the medical doctor, nurses, social worker, physiotherapist and functional therapist [7]. A guardian for the patient’s economic interests was organized. The patient received supportive psychotherapy to deal with the problem and the social worker organized separate living facilities for the mother and son (mother was able to stay in her own home). Additionally weekly contact with other elderly people was organized by the city council and the local church. Our patient also has regular (three times weekly) visits by the nurse from the local health centre in order to support her to be able to stay and function at home (regular medicine usage, buying together products from the local store, etc). As the patient experienced strong fear reactions towards her son, a temporary restraining order was put in place  [8].

 

Learning points:

[1] The WHO has identified various risk factors connected with elderly abuse such as  shared living which was the case here. The apartment in this case was quite small and there is likely to have been  a lack of privacy for both the patient and her son.

[2] EASI, the Elder Abuse Suspicion Index (see appendix) lists various signs that may indicate abuse such as poor eye contact, a withdrawn nature and malnourishment. Most patients refuse to report the abuse; they are ashamed or are afraid of the perpetrator. Another problem is that in hospitals the patient usually does not know the physicians and the lack of trust also prevents them from telling the truth.

[3] Elder abuse does not only cause physical injuries, but can also lead to depression. Patients see no possibility of escape. The patient is depressed and rejects food and wishes to die.

[4] A weak elderly patient or patients with illnesses as well as mental problems are more likely to experience abuse.

[5] Here we see the typical case of elderly women abuse: threats and physical violence based on economical abuse, which gets worse with time. The son has financial problems and is unemployed which might lower his self-esteem. Caring for his mother might be too much for him.

[6] The son is alcohol dependent, which might be triggered by his current unemployment and the worsening financial situation. As the abuse worsens the situation, he is caught in a vicious circle now depending on his mother`s pension which she refuses to share. Dependence on someone is also considered as a risk factor leading to elderly abuse.

[7] This is an excellent example of a positive outcome – a team of various specialists discuss the problem and find a solution, thereby ending the circle of violence. Not only physicians but a multi professional team including a social worker and a legal guardian for the patient’s economic interests to find the best possible solution.

[8] The problems are solved but it is important to consider whether the patient was able to live on her own which might not always be the case. The WHO says that a good network of physicians, nurses and social workers is necessary to tackle the problem of elderly abuse as well as self-help groups for victims, safe houses and shelters.

 

To summarize: this case demonstrates these issues:

 

1. The loss of an older person’s independence can result in a vulnerability that makes them more at risk of abuse.
2. Social factors such as unemployment or financial stress are other factors in abuse scenarios.
3. In some situations, the abuse can be so severe that family breakdown occurs.
4. Alcohol abuse can be a factor in elder abuse, as in other forms of Domestic Violence.

 

Background information:

Finnish population studies tells us that 40% of women 15 age and older become victims of physical or sexual violence. Forty percent of women who live in a long relationship are abused by the spouse (Heiskanen & Piispa 1998).

 

Family abuse is existing in all social groups and the research on the reasons for it, is undeveloped. Risks for family abuse usually are: mutual dependence on each other, living together, social isolation. Economic difficulties and borderline poverty increase the burden on the family in general, weaken female position in the family and damage men ego.

 

In Finland about 50 women die yearly because of the violence directed to them and 2/3 of those die as victims of the domestic violence. Sufferers of the domestic violence, who commit suicide, are left out of these statistics. Restraining order procedure was adopted in Finland in 1999.

 

Elderly women can be subjects to psychological, physical, sexual and economical abuse. In 70 % of the cases abuser is child or spouse. The most common type of abuse of the elderly woman is economical. Special form of abuse is refusal of the family member to help or to treat elderly when elderly is totally incapable to take care of herself. To leave without help when help is needed is an abuse. Victims of the domestic violence use more health system services than other population, but elderly usually are cautious to break the taboo. They experience physical and communicational difficulties in approaching health system, but often shame, guilt and even protection of the family member are on the way.

 

Here we see typical case of the elderly women abuse, threat and physical violence based on economical abuse, which got worse with time. Situation was prolonged and got out of hands because elderly women had physical and psychological weakness, did not want to disclose problems with her son, was ashamed of his alcoholism, and somehow, felt responsible for his behavior.

 

References:

 

1. Heiskanen, M. and Piipsa, M. Faith, Hope and Battering: A Survey of Men’s violence to Women in Finland, Helsinki, Statistics Finland