TheDimensions of ElderAbuse Also by the authors: Alzheimer'sDiseaseandOther Causes ofConfusion by Gerry Bennett Essentials ofHealth CareofOldAge by Gerry Bennett and Shah Ebrahim ElderAbuse: Concepts, Theories andInterventions by Gerry Bennett and Paul Kingston Family Violence andthe Caring Professions edited by Paul Kingston and BridgetPenhale ElderAbuse inPerspective by Simon Biggs, Chris Phillipson and Paul Kingston Reviewing CareManagement edited by Judith Phillips and Bridget Penhale The Dimensions of Elder Abuse Perspectives for Practitioners Gerry Bennett Paul Kingston Bridget Penhale Consultant editor: 10 Campling ©Gerry Bennett, PaulKingston andBridget Penhale 1997 Allrightsreserved.Noreproduction, copyortransmission of thispublicationmaybemade without writtenpermission. Noparagraph ofthispublication maybereproduced,copiedor transmittedsavewithwritten permission orinaccordance with theprovisionsoftheCopyright, Designs andPatentsAct 1988, orunder thetermsofanylicence permitting limited copying issued bytheCopyright Licensing Agency,90Tottenham Court Road,London W1P9HE. Anyperson whodoesanyunauthorised actinrelation tothis publication may beliabletocriminal prosecution andcivil claims fordamages. The authors haveasserted theirrightstobeidentified astheauthors ofthisworkinaccordance withthe Copyright, Designs andPatentsAct 1988. First published 1997by MACMILLANPRESS LTD Houndmills,Basingstoke, Hampshire RG216XS andLondon Companies andrepresentatives throughout theworld ISBN978-0-333-62568-2 ISBN978-1-349-13604-9(eBook) DOI 10.1007/978-1-349-13604-9 /978-1-349-13604-9 Acatalogue record forthisbook isavailable from theBritish Library. Thisbookisprinted on papersuitable forrecyclingand made from fullymanaged andsustainedforest sources.Logging.pulpingand manufacturingprocesses areexpectedto conform to the environmental regulationsofthecountryoforigin. Editing andorigination by Aardvark Editorial, Mendham,Suffolk Toour latefathers whom we miss greatly: Dennis Kingston, Allin Penhale and Jim Bennett Contents Acknowledgements viii Introduction 1 1 Contemporary Overview 6 2 Dimensions ofFamily Violence 38 3 Institutional Dimensions 70 4 Medical Dimensions 100 5 Legal Dimensions and Issues 116 6 Dimensions ofInterventions 153 7 International Developments and the Research Agenda 187 Conclusion 220 Notes 224 References 226 Index 252 vii Acknowledgements There are a numberof people without whom this book would not have been possible. The initial concept for the book came from discussion with Jo Campling who has remained enthusiastic throughout the process; Catherine Gray,ofMacmillan,has been supportive and endur ingly patient, allowing time for necessary changes. Johannah McGowan typed earliersections of the manuscript with unfailing good humour and willingness. The support of our US colleagues Rosalie Wolf and Karl Pillemer always proves tobe inspirational. Fellow trustees from the Council of Action on ElderAbuse continue to inform our thinking and move the debates forward. Thanks are also due to colleagues, many of whom are practitioners, past and present, who stimulate much needed discussion and creativity in this complex area and who are too numerous to name individually. Heads of Departments have been supportive to the endeavour. Our families have experienced much disruption and unavailability throughout the process of this book and yet remain steadfast in their support and goodwill; without them this work would not have been completed. The supportwhich wehave given to and derived from each other has maintained our commitment to the issue and to this book. Any errors or omissions are,ofcourse, our own and are acknowledged as such. The authors and publishers wish to thank the following for kind permission to use copyrightmaterial: Council on the Ageing (Australia) for Tables 7.1 and 7.2 from the Australian Journal on Ageing, 12(4):5-9 (1993), © S.E. Kurrle; The New England Journal ofMedicine for inclusion of work by Lachs, M. and Pillemer, K.,332(7):437-43 (1995); Stanley Thomes (Publishers) Limited forTable 1.3,from Bennett and Kingston (1993). viii Introduction Elder abuse isthe largely unknown violence phenomenon of the 1990s. Although recognised for centuries and reported in the professional press increasingly since the mid-1970s, it is the least acknowledged of the types of human violence. The spectrum of violence has been well publicised with reports of child abuse and spouse abuse, but the entry of another area of abuse has been met by the equivalent of battle fatigue. This seems tobetrue forbothprofessional and layperson. This book seeks to examine the contemporary dimensions of elder abuse.It aims to provide the reader with the accumulated knowledge base concerning this obviously complex human experience. Raising awareness of thereality of elder abuse and the dissemination of information and knowledge about it is fundamental to the education process for the public and professionals. Indeed, it forms part of the mission statement of the only UK charity specialising in the issue Action on Elder Abuse. The range of issues covered in this book provides readers with the basic facts needed to give a solid framework concerning this topic.Each chapter adds dimensions to the framework, allowing the subject to beanalysed from many different perspectives. The typology ofthe differing forms of elder abuse and their societal position and potential cause have been described by Kingston and Penhale (1997) and form a common thread throughout the text. Their typology outlines that for each type of abuse there is a political (macro), community (mezzo) and individual (micro) dimension. This concept is expanded upon in Chapter I. Many people view the essence of any education process on elder abuse as securing the issue as a social problem, i.e. providing a major impact on public awareness.The pathway tothisgoalhas distinct steps, as outlined by Blumer (1971).Recognition as a social problem secures legitimation ofthe issuenotonly bysociety asawholebut moreimpor tantly by 'stake-holders'ingovernment andother important institutions. This book is but one step on that pathway. It does, however, aim to be both educative and informative for a wide readership, from student toseasoned clinician. Toaddress thiscritical audience,the textincludes brief introductory and concluding remarks for each chapter, aiming to allow acover-to-coverupdate on the topic or selective reading. 2 The Dimensions ofElderAbuse Elder abuse as a comparatively recent phenomenon was first described in the UK in the mid-1970s, yet the research and legislative creative force resided in the US for the next 15 years. There has, however, been a significant shift in the last 5 years in this country, as will be seen in Chapter 1, which aims to provide a contemporary overview of the phenomenon in the UK. Understanding some of the issues involved in other forms of abuse can help to shed light on one particular age group - older people. The chapter on family violence, Chapter 2, provides this illumination, pointing out relative similarities and differences between elder abuse and other forms offamilial violence.There is also a focus on the likely predisposing factors and theories ofcausationthat have been developed. Institutional abuse,the violent cancer inthe worldofcaring, hascome of age. This topic is covered in Chapter 3. Of all the dimensions of abuse, it is perhaps the one closest to public awareness due to the frequent scandals that are superficially publicised. The messages are clear, become more refined with the passage oftime, yet continue to be virtually ignored.We know how to recognise and indeed prevent most institutional abuse - by quality: quality staff, quality resources, quality accommodationand quality management. Wealso know how toachieve quality - up to apoint, one has to pay for it. The role of the medical profession within the complex quilt of inter ested parties is rapidly evolving. The ageing population makes reluc tant geriatricians of many doctors. Currentknowledge indicates limited awareness within the medical profession even in countries where education and general awareness are considered comparatively advanced. In the UK, contrary to the situation with child abuse, geria tricians as agroup are not rushing towards the problemand, with afew exceptions, are not in the forefront of education and research into the issue (Vernon and Bennett, 1995). The chapter concerning medical dimensions, Chapter4, outlines what is known about clinical presenta tions of abuse. History-taking and the examination process are funda mental within the medical environment. They provide the building blocks on which adiagnosis is made.Doctors of the future will need to incorporate questions on domestic or institutional violence during the history-taking process to enable them to begin the demanding task of putting together the holistic jigsaw. Expertise in examination and forensic pathology for the general clinicianwill develop away from the current, somewhat crude, associations that tend to be made of 'bruises equal abuse'. The detailed examination process, coupled with expert forensic guidance, will help to inform the situation.Research is essen-