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Behind closed doors: abuse of the elderly patient

Jennie Potter
RGN DN DipHealthCare
National Officer
Elder Abuse Specialist
Community and District Nursing Association

Everyone is familiar with the particulars of Victoria Climbié's horrific death. The details were heavily featured on television news and in newspapers, and the case led to the publication of the Laming report. But the death of 78-year-old Margaret Panting, who died last year in Sheffield, barely made any headlines. Margaret lived with her family and died with over 60 cigarette burns on her body, some as deep as the bone. She also had lacerations over her sacral area, which, according to the coroner, could have been made only by a razor blade. Not only did this case not merit headline news, but nor has anyone been charged in connection with her death.
Surely the elderly deserve the same importance as the young? To protect children, nurses and other professionals now receive mandatory training in the recognition and management of child abuse. The vulnerable and elderly are not so well protected. Not only is there no mandatory training in the recognition and management of abuse of the vulnerable and older person, but also many authorities have no procedures or policies in place to assist staff dealing with abused people, although guidance on developing policies exists.(1)
In our society, domestic violence accounts for over 25% of all violent crime - a woman dies every 3 days as a result of domestic abuse. We have no accurate figures for the vulnerable and elderly who suffer abuse, but a survey in 1991 by Age Concern estimated that between 5% and 8% of elderly people are abused in the UK,(2) that is over half-a-million people, and this is likely to be only the tip of the iceberg.
The Department of Health's prediction that the numbers of those over 80 years of age will double between 1995 and 2025(3) will not only mean a vast increase in the older population, but also indicate an increase in the number of abused.
Our understanding of all family violence and its consequences grows daily. It is now recognised that when one form of abuse is encountered there is the distinct likelihood that other forms of abuse are also taking place. Abuse of older people is often seen as less extreme than other forms of domestic violence, but it is not.
As healthcare professionals working on the frontline, we have a privilege afforded to few - entering behind those closed doors, and trusted in a way few others are. With this trust comes responsibility - we must be equipped to protect those who are vulnerable to abuse. To do this we must be fully aware of exactly what constitutes abuse and be able to recognise potential abusive situations, and that means abuse in all its forms - child, adult and elderly. We not only should recognise abuse but should also be able to deal with it effectively and efficiently. We should be fully aware of the variety of skills other professionals and agencies can offer, so that all knowledge and expertise can be pooled to help the abused. We must know how, who and where to report it, keeping accurate records of all our actions.(4)
It is important to remind ourselves that there is no age, sex, class, religious or cultural barriers to abuse, that it can affect anyone at anytime and that it occurs at all levels of society.
There is also no stereotypical abuser, although in the main they are male, and the majority of victims are female. From information collated from the Action on Elder Abuse helpline, it appears that:(5)

  • 66.7% of abuse takes place in a person's home.
  • 20.1% in residential care.
  • 5% in hospital.
  • 4.2% in sheltered housing.
  • 2.4% in other locations.
  • 1.6% in nursing homes.

Although only approximately 25.9% of reported abuse takes place in care facilities, this is actually a high proportion of abusive incidents, as only 5% of people over 65 years live in such accommodation.(6)
It also appears that the main perpetrators are:

  • Relatives - 44.2% (although not usually the main carer).
  • Paid carers - 27.9%.
  • Nurses - 5%.

The community nurse is not nosy, just observant, because it is part of the job, and as they are in the ­privileged position of being invited into patients' homes it gives them the ideal opportunity to observe the patient's situation. At each visit the nurse continues the process of assessing and evaluating the patient's needs and care, constantly collecting information about them both medically and socially. They are often the only professional aware of any social or domestic problems and so are in an ideal position to recognise and manage abuse. However, in order to do this, the nurse must have been educated and trained in the subject.
Nurses are taught that they must be nonjudgemental, and on the whole we are: we accept that people have a wide variety of standards, values and beliefs, and generally we work around them. However, there must come a time when the nurse says, "this is not acceptable". Abuse is one such case.(7)
The district nurse's caseload tends to be made up mainly of older people with conditions that put them at risk, as well as some younger vulnerable patients.(8) Abuse of these people is not always easy to detect as it is hidden. Hidden by those who are abusing, as they know that what they are doing is wrong, in many cases criminal, and do not wish to be found out. And hidden by those who are abused, because they are frightened and ashamed, feeling that they are in some way to blame for the abuse, seeing themselves as a nuisance, or simply not wishing to admit that people whom they love or trust and rely upon are making their lives so miserable. It is difficult for us to imagine that someone will suffer in silence, or that suffering the abuse is seen as preferable to losing a visitor or going into an "institution" because they can no longer manage alone. The victim may keep quiet simply because they do not want to upset their family, or they may fear that if they do disclose their predicament no one will believe them.
Community nurses are often described as "generalists", but I believe that they are better described as specialists in many areas. For care of the older person they need knowledge about the ageing process and the common problems and disabilities that occur in later life. This specialist knowledge will help them to decide whether the signs and symptoms they see are "normal" or whether they are suspicious and indicative of further illness or abuse. It is only by being knowledgeable and confident to question or seek assistance from other professionals that we can help our patients.
Abuse is not something that fits into nice neat categories and so cannot be identified by using simple tickboxes. Concerns and suspicions may come from a variety of sources - something witnessed, something inferred in conversation or indeed through direct disclosure. Remember that although many vulnerable older people may not consider the incident or behaviour to be abuse, it does not mean that it isn't abuse.
Generally, effective communication with patients is something that should be second nature to nurses - giving people time, varying the ways of communicating if speech is difficult, or finding translators (not family members) if language is a barrier. Research shows that isolation is one of the major factors associated with abuse.(9)
It is important to recognise the difference between "investigating" and "alerting" others about concerns. In terms of identifying abuse or being suspicious that abuse may have occurred, your initial role is gathering information and following policy and procedures from your local area, discussing the situation with your manager and deciding whether a referral for adult protection is required. Many PCTs and social service departments have a named adult protection officer who are usually willing to give help and advice without an official referral.
You are not a one-person adult protection unit - you need to follow good practice policy and procedure to use the information wisely. Acknowledging our professional responsibilities, and keeping up-to-date with our Code of professional conduct, drawn up by the Nurses and Midwives Council,(10) will guide us through what steps we can and should take, not only to protect our patients, but also to police our profession. Hiding behind "confidentiality" is a thing of the past - we can abuse by omission as well as deed.(11)
The Community and District Nursing Association (CDNA) believes that responding to abuse, whatever form it takes, is all of our responsibility. We believe that no one deserves to be abused.
Reducing the incidence of abuse lies in knowledge, and in view of this the CDNA are calling for mandatory education for all staff. The situation will be effectively tackled only by training, encouraging good supervisory practices, good communication and an open environment with no secrecy, and by respecting and supporting those who report abuse and poor nursing practice.
The CDNA are demanding due respect not only for the vulnerable and elderly, but also for those who care for them. We feel very strongly that abuse of older people is a serious and sensitive problem that should be given the same importance as all other types of domestic violence.
The solution lies in every individual and agency responding and cooperating and developing close working relationships. Our efforts to put an end to elderly abuse are embryonic, but we must make sure that we maintain the start that has been made. If each professional could help to alleviate the misery of one abused person then we would have achieved something worthwhile. Not an easy task, but definitely a worthy one!


  1. Department of Health. No secrets. London: DoH; 2000. (In Wales this was called In safe hands.)
  2. Ogg J, Bennett G. Elder abuse in Britain. BMJ 1992;305:998-9.
  3. Department of Health. National Service Framework for older people. London: DoH; 2001.
  4. Community and District Nursing Association. Responding to elder abuse. London: CDNA; 2003.
  5. Action on Elder Abuse. Listening is not enough. London: Action on Elder Abuse; 1999.
  6. Department of Health. Intermediate care (HSC2001/03). London: DoH; 2001.
  7. Nursing and Midwifery Council. Practitioner-client relationship and prevention of abuse. London: NMC; 2002.
  8. Audit Commission. First assessment: a review of district nursing services in England and Wales. London: Audit Commission; 1999.
  9. Bennett G, Kingston P, Penhale B. Elder abuse in perspective. Bucks: Open University Press; 1995.
  10. Nursing and Midwifery Council. Code of professional conduct. London: NMC; 2002.
  11. Department of Health. Confidentiality: a code of practice for NHS staff (Draft). London: DoH; 2002.

Action on Elder Abuse
Astral House
1268 London Road
SW16 4ER
T:020 8764 7648 Helpline:0808  808 8141
Age Concern
Citizens Advice Bureau