ELDER ABUSE AND NEGLECT

Key points

Introduction

Elder abuse and neglect may occur in a number of different settings, including private residences, rest homes and hospitals. There is no international standard definition of the term 'elder abuse and neglect'. The definitions provided by Age Concern New Zealand in their elder abuse and neglect resource kit are good examples of what is generally meant by these terms, and these definitions will serve as the terms of reference for this paper.

According to Age Concern New Zealand, both elder abuse and neglect are distinguished from general criminal activity in that the perpetrator of the abuse or neglect is known to the person being abused and the relationship is one of implied trust.

Categories of elder abuse may be identified as:

• Physical abuse - infliction of physical pain, injury or force;
• Psychological abuse - behaviour that causes mental or emotional anguish or fear;
• Sexual abuse - sexually abusive and exploitative behaviours involving threats, force, or the inability of a person to give consent; and
• Material/Financial abuse - the illegal or improper exploitation and/or use of funds or other resources.

Types of neglect are further defined as:

• Active neglect - conscious and intentional deprivation by a carer of basic necessities resulting in harmful effects.
• Passive neglect - refusal or failure by carer, because of inadequate knowledge, infirmity or disputing the value of the prescribed service, to provide basic necessities resulting in harmful effects.

Causes of elder abuse and neglect

There is no simple explanation as to why elder abuse and neglect occurs. There are, however, several factors that are known to contribute to incidents of elder abuse and neglect:

• dependency of the older person on others for all or part of their care;
• carer stress;
• dysfunctional family dynamics, including a history of family violence and/or alcohol abuse;
• social isolation of both the older person and the abuser; and
• psychological and social problems of the abuser.

The variation of these contributing factors reflect the complexity of elder abuse and neglect and the need to develop responses appropriate to the different causal factors and the particular needs of older victims.

Extent of the problem

Elder abuse and neglect has only recently received recognition. It is therefore difficult to obtain accurate information about its prevalence in New Zealand or internationally. A preliminary examination of international research suggests that between 3% and 5% of older people are subject to abuse or neglect. However, the complexity of elder abuse lends itself to inconsistencies between research definitions, which make reliable comparisons of research findings difficult. Davies suggests that about 3% to 4% of older people in New Zealand are victims of elder abuse and neglect.

Elder Abuse and Neglect Services in New Zealand

Elder abuse and neglect pilot programmes

There are six elder abuse and neglect pilot programmes operating throughout New Zealand: in Whangarei, North Shore, Auckland, Wanganui, Wellington, and Invercargill. The pilots, initiated by Age Concern New Zealand, have been established for about three years. An elder abuse service was already operating in Christchurch before the establishment of the six pilot programmes. This scheme is a joint venture between Age Concern Canterbury, Healthlink South and Presbyterian Support Services.

Each of the elder abuse pilots adheres to the general principles contained in Age Concern's elder abuse and neglect resource and training kit. In general, the pilots consist of multi-disciplinary teams to assist in the prevention of elder abuse and neglect by implementing pre-crisis intervention strategies and responding rapidly to incidents of abuse and neglect. Representatives from the Police, local CHEs and RHAs are involved in the pilots, together with a range of other professional service providers.

Central to the implementation of the pilot programmes is the position of "Regional Co-ordinator". Regional co-ordinators will, in general, act as a first point of contact for all enquiries concerning elder abuse and neglect, and make referrals as appropriate. Lottery Aged grants have funded the salaries of the regional co-ordinators and provided limited administrative costs for each of the pilot projects, which are operated by the local Age Concern Council. North Health Regional Health Authority has also provided some additional funding to the North Shore and Auckland pilots. Local responsibility for the pilot programmes has resulted in differences in the roles of the co-ordinators and in the management of the programmes.

In an attempt to gain improved consistency in the provision and quality of services provided by the pilot programmes, additional Lottery Aged funding was secured in 1994 for the half-time (0.5) position of a national co-ordinator. The main role of the national co-ordinator, located in the national office of Age Concern, is to provide advice to the pilot programmes and the Christchurch programme and to collect and report on data from the programmes.

National Advisory Group on elder abuse and neglect

This advisory group was established by Age Concern to monitor and maintain a general overview of the pilot programmes. Membership of the advisory group includes representatives from Age Concern New Zealand, the Senior Citizens Unit, the Ministry of Health, Police National Headquarters, New Zealand Association of Gerontology, and Alzheimers Society. Advisors affiliated with Maori Women's Welfare League, Pacifica and the Social Policy Information Service of the Social Policy Agency also provide advice to the National Advisory Group.

National Advisory Group's report to Ministers

In September 1995, the National Advisory Group prepared a report, Elder Abuse and Neglect in New Zealand, to the Minister for Senior Citizens, the Minister of Health and other interested parties. The report provided information on the progress of the pilot programmes and other issues relating to elder abuse in New Zealand. The report was expected to include information collected from the pilot programmes to assist Government in deciding: which government agency should have primary policy responsibility for the area of elder abuse and neglect; the level of resources to be allocated to the area; and whether the pilot projects initiated by Age Concern New Zealand should be extended to other centres throughout New Zealand.

The major recommendations from the National Advisory Group's report were:

• the introduction of elder abuse and neglect services throughout New Zealand to respond to and prevent an expected increasing number of reported incidents of elder abuse and neglect; and
• the establishment of an officials group to consider the most appropriate government agency to take responsibility for furthering work on the introduction of the elder abuse and neglect services and to make recommendations on how these services might be funded.

Minister's response

Officials represented on the National Advisory Group agreed that the pilots demonstrated an ongoing need for intervention and prevention strategies to combat elder abuse and neglect in New Zealand. They recognised, however, that Government requires sound evidence on which to base any decision regarding funding and policy responsibility for elder abuse and neglect services. It became apparent during the preparation of the report that the data collected from the pilots was incomplete.

The Minister for Senior Citizens agreed that a decision regarding agency responsibility for the policy and funding of elder abuse and neglect services would best be made by Government following collection of adequate information from the pilots. This decision requires the pilot programmes and the Christchurch programme to continue with funding from Lottery Aged, and delays the consideration of government funding for other elder abuse and neglect services until adequate information has been collected from these services. In order to achieve this, the data collection and analysis is being undertaken by the Social Policy Information Service of the Social Policy Agency. This data collection is expected to be completed by December 1996 and a report to the Minister for Senior Citizens will follow. The purpose of the report will be to advise Government on the incidence of elder abuse and neglect in New Zealand and also to make recommendations on how current and future elder abuse and neglect services could be funded.

Service Development Issues

National model for elder abuse and neglect services

Elder abuse and neglect intervention services are currently being developed on an ad hoc basis to meet local demands in other areas of New Zealand. The lack of policy responsibility for elder abuse and neglect services increases the risk that developing services will not provide a consistent or appropriate standard of service. Operational differences between elder abuse and neglect pilots which affect the delivery of services have already been identified. The lack of a single funding source for services increases the risk of inconsistency between services.

Age Concern New Zealand has attempted to encourage consistency in the provision of services by providing advice and relevant resource materials, such as the elder abuse and neglect kit, to developing intervention programmes. To date, a comprehensive service has been established in North Shore, funded by Age Concern North Shore, funds from the local community and from North Health Regional Health Authority. In addition, fledgling services are developing in Hamilton, Napier, Taupo, Palmerston North, Ashburton, Waitake and Dunedin. The level of service available in these centres is limited due to funding difficulties. Age Concern New Zealand is providing advice and information to these developing services.

In its report to Government in early 1997, the National Advisory Group is expected to recommend a preferred model for elder abuse and neglect services in New Zealand. The recommended model will result from a comparison of the six Age Concern pilot programmes and the Christchurch model.

Refuge

An area of particular concern to those who currently work in the area of elder abuse and neglect is the lack of suitable refuge for victims of elder abuse and neglect. Places of safe refuge must be sensitive to the needs of older people, not merely on the basis of their age, but also in terms of their gender, ethnicity, cultural values and health status.

Women's Refuges cater primarily for women and children who have been subject to abuse, usually by a male partner. The needs of older women who are victims of elder abuse and neglect, possibly from another family member, but also from other caregivers or service providers, are in the main different from those of younger women and their children. As such, these refuges are not usually an appropriate avenue of assistance for older women. There is no equivalent refuge for older male victims of abuse.

Rest homes and hospitals have been considered and are used in the pilot programmes as alternative refuges. However the use of rest homes and hospitals present problems both in terms of appropriateness and cost in many cases. Rest homes and hospitals are unable to provide the element of safety necessary for true refuge, and admissions of victims of elder abuse and neglect to these institutions may in fact put other residents at risk. Furthermore, many continuing care hospitals or rest homes do not have staff with the expertise necessary to provide the counselling and support that may be needed by older people in these situations.

The use of private homes as emergency short term refuge for elder abuse victims is being trialled by some of the Age Concern pilot programmes. Again, concerns about the level of quality of care and the safety of both victims and carers means that the use of private homes as refuges may not be appropriate.

Culturally appropriate services

It is recognised that any policies or programmes developed to address the issues of elder abuse and neglect must be culturally appropriate if they are to render positive results. Maori and Pacific Islands people's participation is being sought in each of the pilot areas, and those involved in the pilots agree that a greater effort needs to be made to develop links with local groups, and to recruit their assistance as appropriate. Early feedback from the project teams indicates that elder abuse and neglect is as prevalent amongst Maori and Pacific Islands communities as it is in other communities, and that the custom of "looking after one's own" can make the disclosure of such abuse particularly difficult for these groups.

Policy Issues

Education

Elder abuse has not gained the same high profile as child abuse in the community, yet if overseas trends are followed, it will become more of an issue as public awareness is heightened. Currently there are not adequate resources to deal with the issue, and there is still a need for preventative measures in the form of public education.

Age Concern New Zealand has recognised the importance of education and has taken this educational role upon itself. The organisation has been assisted by funding for the development of resource material from the former Public Health Commission. Education about elder abuse and neglect is regarded by the National Advisory Group as integral to the role of the pilot co-ordinators. In their work to raise awareness about elder abuse and neglect, pilot co-ordinators spend a significant time speaking to community and public groups, and to health professional students. The question of who is to take responsibility in the long-term for such education needs to be addressed. This issue is expected to be discussed in the National Advisory Group's report to Ministers in early 1997.

Effect of the Domestic Violence Act 1995

The first opportunity for legal protection of older people in a domestic relationship other than marriage is provided in the Domestic Violence Act, effective from 1 July 1996. Due to the personal relationship with their offenders, victims of elder abuse have tended not to want legal action to be taken against offenders. It is not clear whether the new legal provisions, which mean that most offenders could be dealt with in the Family Court rather than the District Court, will result in an increase in legal action being taken against perpetrators of elder abuse and neglect. The effect of publicity about the Act on the number of incidents reported is also unknown.

Community care

The link between carer stress and the incidence of abuse and neglect has been well established. As government policies move progressively away from institutionalisation and towards community care, where increasing responsibilities are placed on family members in particular, it is imperative that appropriate support services are introduced. Unless adequate support services for family carers, including respite care, are available, the risk of elder abuse and neglect will increase.

The need for assessment in order to access caregiver support services is included in the 1996/97 Policy Guidelines for Regional Health Authorities released by the Minister of Health. Accordingly, the previous entitlement of up to 28 days respite care has been replaced with the provision of respite care on the basis of individual need. This means that, in some cases, less than 28 days may be provided while in others more than 28 days may be available to assist family caregivers.

Access to 28 days respite care was previously available for caregivers on the recommendation of a general practitioner. The change in policy now requires the person being cared for to undergo a geriatric assessment by a multi-disciplinary assessment and rehabilitation team. There is public concern that this change in policy means that access to respite care for caregivers is reduced. There is also public concern that access to respite care will be delayed for many clients due to fact that waiting lists for assessment services already exist in all regional health authority areas. The Senior Citizens Unit has been advised that all regional health authorities have developed processes to ensure that clients with urgent needs have priority for assessment services. The Unit intends to monitor whether family caregivers are receiving appropriate support.

Service providers supplying home-based support services to older people in their own homes will also require careful monitoring. Services provided in the home are more difficult to oversee than those based in an institutional setting. Educational programmes for home-based service providers, together with a protocol for supervising and monitoring of services provided in the home, will go some way towards reducing the likelihood of abuse and neglect in the home setting.

Mandatory reporting

As with child abuse, the issue of the mandatory reporting of elder abuse has been raised as an option for increasing awareness and increasing protection of those most vulnerable to abuse and neglect.

Mandatory reporting of elder abuse and neglect is seen as a potentially expensive option that may do little to improve the situation of older people, and in some cases could result in a worsened situation, for example, the inappropriate institutionalisation of older people. In addition, mandatory reporting may inhibit the reporting of elder abuse by victims, thus compromising their autonomy, dignity, and self-esteem.

Such arguments against mandatory reporting have been similarly noted in other countries. The New South Wales Task Force on the Abuse of Older People, for example, concluded that arguments against mandatory reporting are currently stronger than those in support of it.

The Senior Citizens Unit supports the view that rather than introducing mandatory reporting, it is preferable to use all possible means to inform and empower older people, their families and formal caregivers to take measures to prevent abuse in the first instance.

Future Directions

The issue of elder abuse and neglect has only recently gained recognition in New Zealand. As public awareness of elder abuse and neglect grows, the demand for services to deal with the problem will intensify. Unless the Government, through one of its agencies, takes responsibility for service provision in this area, the problem is likely to remain largely hidden, to the detriment of older people, their families and their caregivers.

The collection of data on the actual incidence and types of elder abuse and neglect prevalent in New Zealand will provide a sound base from which government strategies and intervention and education programmes may be developed. Data is currently being collected from seven elder abuse and neglect programmes but further data and research on elder abuse in New Zealand will be required.

The National Advisory Group for elder abuse and neglect will be reporting to the Minister for Senior Citizens and the Minister of Health in December 1996 on elder abuse and neglect in New Zealand. The report will provide recommendations on a preferred model for elder abuse services and the funding of those services.

Officials represented on the National Advisory Group, from the Senior Citizens Unit, the Ministry of Health and NZ Police, will then provide comment on the report and provide recommendations on funding guidelines, co-ordination of elder abuse and neglect services in New Zealand and strategic issues related to those services. The Senior Citizens Unit will be seeking your agreement to refer these recommendations for consideration by Cabinet early in 1997.

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