Case 25

Domestic violence against the elderly in Germany

Objectives

  1. To illustrate that domestic violence can be overlooked due to a lack of knowledge
  2. To show as best case example a succesful intervention of a GP
  3. To demonstrate that it is not always clear – domestic violence case or not?

Narrative cases:

  1. Domestic violence not recognized due to lack of knowledge

During a home visit as a general health practitioner, I saw a family at an isolated rural location (edge of Wuppertal in Germany). A lady of around 80-years of age presented in a weak state [1] with various pains in different places caused by several falls. The patient herself was silent and her home, clothing and family seemed rather neglected. [2]

After writing an admission note for the hospital, I had the vague feeling that something was being withheld from me.  I had asked the family to call an ambulance but should have waited for the ambulance to arrive. I realized this much later when I learnt more about violence against elderly people within the family. [3]

2. Successful intervention of the GP

An 85-year-old woman was said by her family to be unable to pass urine and suffering from severe abdominal pains. This history was given in an excited and wordy account. The patient was very restless, anxious and her bladder clearly full. While writing down the results of my examination, I hear the patient ask her family: “Can I now go to the toilet?” and hear a hissing whispering: “No”!

I wrote a hospital admission note and called the ambulance myself. [4] I had the suspicion that the family had forced the patient not to go to the toilet. I think they did not know how to care for the grandmother and feigned illness in a very clumsy way to bring help from outside. [5] Soon after the visit, I informed my colleague on duty at the hospital about my suspicion. [6] After admission, the patient had been able to pass urine without any problems. Social/familiar background problems could be solved at the hospital by a special care service for needy and lonely patients. [7]

3. Unclear situation- case of domestic violence or not?

A patient on my list  for over 10 years [8], aged 87 years, lived after her daughter’s death with her son-in-law in a detached family house [9]. The patient was suffering from cardiac insufficiency and repeatedly she came with injuries and excoriations on her legs to my private practice. “She is always running down the stairs too quickly!” said the son-in-law who accompanied her. His behaviour was then rather uncooperative and disturbed. The patient insisted that she was kindly nursed by him [10] and a niece with a nurse living nearby looked after her [11].

Until now I have not known what to think about the situation [12]

Learning points

[1] The WHO state there are several risk factors concerning elderly abuse such as illnesses and shared living situations. In addition,  strong dependence on caregivers can make such abuse more likely.

[2] Elderly  abuse can have many different forms and involves more than physical components. The neglect of an elderly person, whether intentional or not, is also considered as abuse. At times, it is difficult to determine whether it is already abuse or still unkemptness.

[3] Here the main problem is described; the general lack of knowledge regarding this topic. The physician did not even think about it! Not only are there few studies on this topic but there are also no reports on this issue worldwide. The topic itself is also regarded as taboo (should stay within the family) and no-one wants to talk about it, which makes recognition even more difficult.

[4] In comparison to the first story, the physician recognized the abuse and decided to intervene. She stayed and made sure that the patient went to hospital.

[5] In this example, the family is clearly overburden with the care of the old lady. They wanted to get help from outside but didn´t know how to do this. The physician was sensitive to the issue but as the awareness is not very high many cases can go undetected. The WHO started preventative programmes for people who are caring for their older relatives. These provided assistance and teaching on how to deal with the situation.

[6] Here we see the positive impact of an intact chain of information between physicians. The physician at the hospital is informed about the suspicion and can further intervene.

[7] This is a best practice example. In most hospitals such a special service is not available. It will assist families that want to get help.

[8] The physician knows the patient for a very long time and the family situation as well. If a relationship like this exists, a physician can recognize changes faster and usually some kind of trust exists between doctor and patient.

[9] Another risk factor is social isolation. It goes together with dependency as the abused person might have only the abuser as their sole contact person.

[10] The physician suspects abuse but does not get a sufficiently detailed answer. Here a standardized sample of questions might help which can be answered with yes or no. Questions like this do already exist such as the H-S/East (Hwalek-Sengstock Elder Abuse) screening test. Recently the WHO has tried to develop a more simple approach using 12 easy to understand questions, EASI – The Elder Abuse Suspicion Index. These questions can be found on the internet (see below). It might also help to question the patient in private. There are many reasons why potential victims do not want to talk about abuse including feeling afraid to be alone or feeling  ashamed.

[11] Once again the importance of a network is seen. The physician could contact this nurse and talk with her about the situation in the patient´s home. In addition, the physician could visit the patient to check the situation for herself.

[12] As already described in [2] it can be rather difficult without screening tools to determine abuse. This underlines the importance of raising awareness and proper training for physicians

Further Information

According to the WHO 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. It can have many different forms such as physical, psychological or emotional, sexual and financial.

The importance of this topic has long been underestimated but it has gained growing attention. Still elder abuse is believed to be underreported by up to 80% with a prevalence ranging from 1% to 35% according to various questionnaires. There exists a remarkably lack of studies concerning it. The biggest study regarding this topic was in 2002 the Missing voices: views of older persons on older abuse study conducted by the WHO. It was conducted in eight different countries: Argentina, Austria, Brazil, Canada, India, Kenya, Lebanon and Sweden.

This study demonstrated the necessity of addressing this topic. The WHO has started to develop screening tools to make it easier to raise physicians’ awareness and help to detect more cases. Different methods and questionnaires previously used such as the H-S/East but were regarded as taking too much time to ask, were difficult to understand and non specific. Taking these issues into account, EASI the Elder Abuse Suspicion Index was drawn up which consists of only six questions of which five are answered by the patient and the last one by the doctor.

 

The WHO identified five fields of risk factors:

  1. Individual: illnesses (mental disorders, alcohol abuse), gender (in countries where woman have a lower society status than men, they are more likely to experience elder abuse)
  2. Relationship: shared living situation, dependence, financial dependence of the caregiver on the elderly person, history of poor relationships within the family, overburden of the caregiver
  3. Community: social isolation of the elderly person
  4. Socio-cultural: financial problems, general depiction of old people as weak and helpless, erosion of bonds between the generations, migration of young couples
  5. Institutional: low standards, poorly trained and overworked staff, economic reasons (the economic situation of a home for the elderly is more important than the well-being of its residents)

 

As with any type of abuse, elder abuse can cause not only physical injuries but may lead to long-lasting psychological problems such as anxiety and depression.

After raising awareness, the WHO proposes various measures to tackle this form of abuse such as a general screening for abuse and better caregiver support and training. They are demanding mandatory reporting on each case, building  safe houses and shelters for victims and the foundation of self-help groups.

All these measures show great similarity to the measures against domestic violence.

HWALEK-SENGSTOCK ELDER ABUSE SCREENING TEST (H-S/EAST)

Purpose: Screening device for service providers interested in identifying people at high risk of needing protective services.

Instructions: Read the questions and write in the answers. A response of noto items 1, 6, 12, and 14; a response of someone elseto item 4; and a response of yesto all others is scored in the abuseddirection.

 

  1. Do you have anyone who spends time with you, taking you shopping or to the doctor?
  2. Are you helping to support someone?
  3. Are you sad or lonely often?
  4. Who makes decisions about your lifelike how you should live or where you should live?
  5. Do you feel uncomfortable with anyone in your family?
  6. Can you take your own medication and get around by yourself?
  7. Do you feel that nobody wants you around?
  8. Does anyone in your family drink a lot?
  9. Does someone in your family make you stay in bed or tell you youre sick when you know youre not?
  10. Has anyone forced you to do things you didnt want to do?
  11. Has anyone taken things that belong to you without your O.K.?
  12. Do you trust most of the people in your family?
  13. Does anyone tell you that you give them too much trouble?
  14. Do you have enough privacy at home?
  15. Has anyone close to you tried to hurt you or harm you recently?

EASI Questions

Instruction: Q.1-Q.5 asked of patient; Q.6 answered by doctor

Within the last 12 months:

  1. Have you relied on people for any of the following: 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 shamed or threatened?
  4. Has anyone tried to force you to sign papers or to use your money against your will?
  5. Has anyone made you afraid, touched you in ways that you did not want, or hurt you physically?
  6. Doctor: Elder abuse may be associated with findings such as: poor eye contact, withdrawn nature, malnourishment, hygiene issues, cuts, bruises, inappropriate clothing, or medication compliance issues. Did you notice any of these today or in the last 12 months?

 

Sources

  1. WHO. A global response to elder abuse and neglect. 2008. ISBN: 978924156381 http://www.who.int/ageing/publications/elder_abuse2008/en/ (25.09.2015)
  2. WHO. Discussing screening for elder abuse at primary health care level. 2008. ISBN: 978 92 4 159453 0. http://www.who.int/ageing/publications/discussing_screening/en/ (25.09.2015
  3. WHO. Missing voices: views of olfrt persons on elder abuse. 2002. http://www.who.int/ageing/publications/missing_voices/en/ (25.09.2015)
  4. Fact sheet on elder abuse. http://www.who.int/mediacentre/factsheets/fs357/en/. Dec. 2014. (26.09.2015)
  5. The elder abuse suspicion index. https://www.mcgill.ca/familymed/research-grad/research/projects/elder. 2015 (28.09.2015)
  6. http://www.medicine.uiowa.edu/uploadedFiles/Departments/FamilyMedicine/Content/Research/Research_Projects/hwalek.pdf (28.09.2015)
  7. https://www.mcgill.ca/files/familymed/EASI_Web.pdf (28.09.2015)

Case 19

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