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Breaking the Silence
An Ad Hoc Newsletter of Family Service Association of Toronto’s Elder Abuse Consultation Team Download PDF
The Impact of Elder Abuse on Health
June 15, 2007 marks the second world elder abuse awareness day.
First celebrated in 2006, this day was declared by the International Network for the Prevention of Elder Abuse (INPEA) to bring awareness to the issue of elder abuse across the globe. Individuals, organizations, seniors groups, governments and all others concerned about the abuse of older adults are encouraged to sponsor and/or participate in awareness raising events.
A review of events planned for 2007 indicate a wide range of forums, educational sessions, health fairs etc being planned. Some examples include an event planned at the World Health Organization in Geneva, Switzerland on June 14 and 15. Stephen Lewis is one of the featured speakers at this event.
There will also be a series of web casts prior to and on the day on elder abuse for service providers. Other events planned in countries as diverse as Israel, Brussels, the United Kingdom and Korea include a mixture of conferences, garden parties, declarations in houses of parliament, quizzes and other awareness raising activities.
This year, the Seniors and Caregivers Support Service Unit at Family Service Association of Toronto is very busy on June 15. A group of seniors will be hosting an awareness raising session in the morning. They will be working with a facilitator to stage a mini-theatre production.
The manager of the SCSS team will be doing a presentation at Scarborough Hospital in the morning and the afternoon will be devoted to a meeting of Family Service Association of Toronto's Elder Abuse Consultation Team. Another team member will be joining the North York Elder Abuse Network at Centrepoint Mall where we will have a display board on elder abuse.
What the research says
When people are asked which issues they care about most, invariably health care falls within the top three priorities of Ontarians. As a population we treasure our health care system but are being told over and over again by academics, journalists and politicians that health care costs are threatening to take over the budget of the government of Ontario.
It is well known that health care utilization rates increase with aging. Indeed, on a national basis, statistics suggest that seniors account for 39% of Canada's health care costs, while representing 12% of the population (Spencer, 1999).
The cost of many different diseases has been studied and there has been much discussion of the importance of the development of a chronic disease management framework in Ontario to manage health care. However, less attention has been paid to some of the "hidden costs" that may be associated with both acute and chronic illnesses, including abuse. The need to direct our attention to this area of inquiry is critical in light of findings by Bowlus et al (2003). The cost of providing short, medium and long-term services to children and adults, where their health issues may be related to child abuse was $2,041, 200, 981.
Estimates suggest that 2-10% of older persons will experience some form of abuse in their later years. Researchers and clinicians alike believe this number to be very conservative. However, even if we accept that 1 out of every 10 older people are victims of elder abuse this means that up to 160,000 people over the age of 65 are affected by abuse in the province of Ontario (Stats Canada, 2000). Based on this fact, the impact in real dollars on our health care system is hugely significant.
Findings from two large U.S. research projects have documented the deleterious effects of abuse in the later years. Lachs et al (1998) found that victims of elder mistreatment had a much poorer survival rate (9% vs. 40% of non-victims) at the end of a 13 year follow up. The 176 members of this cohort were all connected to Elderly Protective Services (somewhat akin to the Office of Public Guardian and Trustee in Ontario), suggesting they were more seriously compromised cognitively.
A recent study on community dwelling, functionally independent older women, who were cognitively intact and ranged in age from 50-74 reveals that 58.5% of women reported experiencing abuse over their adult lifetime. Of these women, 5.2% to 22.8% reported experiencing some form of abuse within the past 12 months.
When we put these two studies together we learn that cognitively intact individuals experience more mental health issues while cognitively compromised persons experience a higher rate of chronic disease. It is argued that these chronic diseases can be made worse by the presence of abuse in a relationship. It is also suggested that poorer overall mental health may have an effect by accelerating age-related declines in health status. It is known that health status is connected to overall life expectancy and influences health service utilization.
Translating academic findings into practice
- Has someone you know become highly anxious over what appears to be a seemingly small issue?
- you know anyone who has frequent falls that don't seem to be explained in any coherent or logical way?
- Are you working with someone who works very hard to control their world around them and, as a consequence, finds it very difficult to connect with people and/or maintain a working relationship with a health care provider, stay connected with friends and so on.
- Have you had the same senior show up in your emergency room or family practice or seniors program and heard them complaining of somewhat vague but persistent symptoms that no one seems to be able to get a handle on?
- Have you had the experience of working with someone who is very anxious and makes you feel the same way?
If any of these scenarios (and hundreds of more possibilities) sound familiar, chances are the person you were dealing with may have experienced abuse at some point in their life.
One of the challenges when working with older people is making sure we are listening, looking and treating the WHOLE person. This is particularly true as older people come into contact with the health care system. There are many pressures brought to bear to quickly determine what is wrong, categorize it as a disease process and then recommend and implement a course of treatment.
When dealing with someone who is older, there are many medical conditions that can be associated with aging. It is critical to determine if these conditions have a medical etiology to them and/or if they are triggered and/or complicated by the presence of one or more types of abuse. Some examples include:
- Depression
- Fatigue
- Confusion
- Anxiety
- Eating difficulties
- Sleep disturbances
- Self-neglect
- Paranoia or fear of institutionalization
- Withdrawal
- Refusal to follow doctor's orders
- Apparent over-focus on health
- Over/under use of medications
- Apparent inability to learn new things/ acquire new knowledge
When an older person presents with one or more of these issues, it is important to take a step back and ask about what is going on in the older person's life. Get an idea of what a typical day is like (i.e. who they interact with or don't, if they are free to come and go as they like, etc). If they are feeling pressure from anyone close to them (and if so, what about), if they live alone or with someone else can all be important questions to ask before moving on to a diagnosis.
People who are abused almost always show a degree of confusion. This occurs because of the inconsistent messages they receive about their self worth and value in the world. They may be praised one minute and put down the next. This can also precipitate anxiety and depression due to a lack of certainty about what comes next. Refusal to follow doctor's orders may be due to threats or "suggestions" by perpetrators that their doctor is wrong.
The use of medications to cope with abuse should never be underestimated. In our clinical work at Family Service Association of Toronto, clients have told us many times that they self-medicate to deal with difficult situations (i.e. take a sleeping pill in the middle of the day so they don't have to deal with their adult child harassing them for money). Under use of medications can often be connected to the fact the older person may not have the funds available to pay the co-payment required or the perpetrator is withholding access to medications or is using them for themselves.
Sometimes people can present with a bewildering array of physical and/or mental health challenges. Often it is hard to get a good history from the person, which can cause frustration and anxiety amongst service providers.
A short list of chronic physical health conditions that have been linked to abuse include:
- Sleep disorders
- Eating disorders
- Migraines
- Diabetes
- Heart disease
- Hypertension
- Fibromyalgia
- Cancer
- Osteoporosis
- Asthma
- Anemia
- Lung disease
- Liver disease
- Thyroid malfunction
- Irritable bowel syndrome
- Gynecological problems
- Chronic pelvic pain
- Inflammatory bowel disease
- Chronic neck and back pain
- Sexually transmitted infections
The effect of abuse on the emotional well-being of victims is well documented as well. Mental health challenges that are encountered can include:
- Sleep disturbances
- Anxiety (acute and chronic)
- Suicidal tendencies and/or suicide attempts
- Paranoia
- Post traumatic stress disorder (PTSD)
The health effects of abuse persist while a person lives in an abusive relationship but can also continue for many years. Many survivors have told us that the emotional impact is far greater than the physical. Researchers suggest this may be due to the prolonged repeated trauma that occurs when people are under the control of a perpetrator. Much like a hostage situation, people who are abused are rendered powerless due to the coercive control being exercised over them.
While it can be difficult to respond to the special needs of persons who are abused it is important to think "outside the box".
Interventions to consider when working within the health care system
Creativity, perseverance and flexibility are key attributes when working with older persons who are abused. Being able to pace your work at the level and speed of the individual is critical to ensuring that the person feels safe enough to disclose what is happening in their lives.
- It is often said by clinicians who have worked with younger women who are abused and are now working with older women that the work takes three to five times as long. This is due to many factors including the long histories of abuse, the lack of resources and the need to do significant advocacy to access supports.
- Respect the rights of the person who is abused to make decisions for themselves, at their own pace. This may mean several different discussions are needed at different times in a private space. It is important to not only listen but to offer active and respectful responses that validate the person's experience.
- If you know or suspect abuse is occurring, work with the person to develop a safety plan. Identify their strengths, how they have kept themselves safe in the past and what they will do in the future (see www.fsatoronto.com/programs/seniors/factsheets.html - area with safety planning OSS sheet)
- For some, the hospital or doctor may be the only potential source of outside contact. It is vital that older people be seen by medical personnel for some portion of their health care interaction without anyone present. This is as important when a person is cognitively intact or not.
- In some instances, the doctor's office can be used as a way to "call in" patients who have not been seen for some time and where there may be some questions about possible abuse. Being called in to a doctor's appointment can be a safe way for an abused older person to seek help. She has a legitimate reason for leaving the home.
- Sometimes people who come into contact with a person who is being abused become concerned about asking too many questions for fear they may trigger a response that they do not have the time, mandate and/or skill to respond to. Being actively connected to networks within the community, where people come together on a regular basis to share information can be invaluable. These networks can be used to conduct anonymous consultation and/or one or more members could be invited to meet with the older person (if they agree). Work can be done together, as a team, to develop a plan with the older person about how they wish to move forward.
- If the perpetrator has a history of cancelling services that the older person needs and wants, the abused individual can be asked to give direction in the event this happens (i.e. come anyways, sign a letter that directs the service provider only to take direction for the older person experiencing abuse themselves, have the older person give consent to contact the police in the event services are terminated and/or interfered with by the perpetrator.)
- The older person can be coached to develop a special code word or phrase to use with service providers if they can not talk freely either on the phone or during a home visit. A plan can be put in place to determine how follow up would occur (i.e. visitor to the home asks the older person to go for a walk outside etc).
- It is important to realize that a power of attorney for personal care can not use this authority to block access to a person or withdraw consent for services if the person is capable.
- Feelings of worthlessness and helplessness can be deeply ingrained in older people who experience abuse. Working with a person to determine their past strengths and coping mechanisms is critical. Designing interventions that allow a person to feel control over one small part of their life at a time is critical. For example, helping a person to bring order to their day, breaking down tasks into small, "do-able" pieces or responding to very practical needs can help to regain control.
- Documentation of any injuries is critical. A sample document is provided at the end of this newsletter. It was developed by the World Health Organization and the International Network for the Prevention of Elder Abuse. Numbering of injuries noted and then making notes about their colour, shape, length etc is critical. This document should stay on the client's file.
- It is critical that a potential perpetrator's ability to be abusive is never underestimated, even if he/she is physically frail or compromised, diminutive in stature or the sweetest person you have ever talked to!!
- People with dementia can become abusive as part of the disease process. However, people with dementia may also have a long history of having been abusive prior to the illness. It is important that a thorough history is taken with the family and detailed questions are asked about what the person was like pre-disease. This will help service providers to understand what they are dealing with and the best ways to support families. In some instances, the person who is labeled the "caregiver" may not be prepared to support the ill individual. They should not be forced to do so if this is the case.
Clinical Services Offered at Family Service Association of Toronto for Older People who are Abused
The Seniors and Caregivers Support Service Unit at Family Service Association of Toronto provides clinical social work services to older people experiencing abuse. The team also works with family members who may be concerned that an older relative is being abused. From time to time the team also works with perpetrators of abuse. The following services are offered:
- Crisis intervention
- Safety planning
- Counselling
- Individual client education
- Individual advocacy
- Group based programming
- Caregiver counselling
- Caregiver Education
- Caregiver Support groups
- Research and evaluation
- Systemic advocacy
- Supporting self-help groups
- Connecting to resources
Eligibility for service includes:
- Client lives or works in Toronto
- Age 60 years of age or older or a person with a disability 50 years of ago or older (exceptions are made on a case by case basis)
- Home visits will be conducted where needed and it is safe for staff to visit. Alternatives include community based contacts and/or office visits.
Fee Structure
All clinical services are provided free of charge. To refer a client, please contact our Service Access Unit at 416-595-9618.
Trainings offered on the addressing the issue of abuse of older persons
The Seniors and Caregivers Support Service Unit at Family Service Association of Toronto provide training workshops for seniors groups, the general public and service providers, on a variety of topics. Examples include:
- Elder Abuse 101 (Includes definitions of abuse, signs, criminal code offenses)
- Indicators of abuse (covers social, behavioral indicators)
- Assessment and Intervention
- Safety planning
- Capacity issues
- Responding to a revelation of abuse
- Engaging with older people who are abused
- Working with perpetrators of abuse
- Documentation
- Developing protocols
- An interactive training program on older woman abuse
- Developing an elder abuse consultation team
- Taking a consultation team to "the next level"
COMING SOON
- Differentiating caregiver stress from abuse
- An interactive training on safety planning
New trainings are identified on an as needed, as requested basis.
Fee Structure
All trainings are provided to seniors and the general public free of charge.
Trainings for service providers are based on an hourly rate. Fees will be negotiated to meet individual circumstances.
For further information about any training services provided, please contact Lisa Manuel at 416-755-5565 ext 422 or lisama@fsatoronto.com
Elder Abuse Consultation Team
This multi-disciplinary team is in its fifth year of operation. People working with individuals who are being abused are encouraged to bring forward cases for anonymous review and support. The team meets once a month on the following dates:
Friday June 15, 2007 Friday Oct 19, 2007
Friday July 13, 2007 Friday Nov 16, 2007
Friday Sept 21, 2007 Friday Dec 14, 2007
Consultation support is also available by phone. For more information about the team please contact Lisa Manuel at 416-755-5565 ext 422 or lisama@fsatoronto.com
Financial Support for the work of the Elder Abuse Consultation Team
Currently the EACT has no funding to support its work, however we are committed to keeping the team together. If you are interested in making a personal donation or providing corporate support please contact Theresa Sit, Development Coordinator, at 416-595-9230 ext. 237 or e-mail: theresasi@fsatoronto.com.
Resources
Websites
www.inpea.net - Visit this site for more information on the International Network for the Prevention of Elder Abuse and information about World Elder Abuse Awareness Day.
www.cnpea.ca - This website provides information to raise awareness of key issues around abuse and neglect in later life and to assure older adults are treated as full citizens in Canadian society.
www.onpea.org - The Ontario Network for the Prevention of Elder Abuse has launched an on-line training program for personal support workers on the topic of abuse of older adults. It also has an extensive curriculum posted on the site and links to many resources etc across Ontario.
Articles
Mouton, C (2003) "Intimate partner violence and health status among older women". Violence Against Women: 9(12): 1465-1477.
Haskell, L (2001) Bridging responses: A front-line worker's guide to supporting women who have post-traumatic stress. Toronto: Centre for Addiction and Mental Health.
Zink, T (2006). "A lifetime of intimate partner violence: Coping strategies of older women". Journal of Interpersonal Violence. 21(5): 634-651.
Books
Brandl, B et al (2007) "Elder abuse detection and intervention: A collaborative approach". New York: Springer Publishing Company
Journals
Journal of Elder Abuse and Neglect
Violence Against Women
Researcher: Keisha Simpson, Lisa Manuel
Contributors: Lisa Manuel, Brenda Anderson, Jane Zhang, Beverley Kelley, Chantelle Harriott, Rebecca Choy, Jose Benvenuto, Lynne Gallagher
Editors: Brenda Anderson, Lisa Manuel
Reproduction
We encourage reproduction of this newsletter (with credit attributed to Family Service Association of Toronto) in part or full for purposes of translation, training and public awareness.
