It was not just the fresh bruises on the 70-year-old patient’s arms and legs that triggered the doctor’s suspicions. The elderly patient had also shut down and averted his gaze when the doctor questioned him about them. His son also refused to leave the patient’s side, which caused the doctor to suspect that it might be a case of elderly abuse.
But there was not much that the doctor could do. He could not verify his suspicions, and he realised the elderly man might not want to complain as he was reliant on his caretakers.
This is the dilemma faced by family and primary care practitioners when presented with cases of possible abuse and neglect of the elderly.
“When it comes to children or women who suffer abuse, there are clear protocols and guidelines on how doctors should respond. But when it comes to elder abuse, there are none,” says Universiti Malaya (UM)’s Medical Faculty’s Primary Care Department lecturer Assoc Prof Dr Sajaratulnisah Othman.
Doctors are trained to handle child and domestic abuse cases but have no guidelines to follow up on suspicions of elder abuse.
They know, for example, that under the Child Act 2001 they are required to report any concerns or suspicions that a child may have been abused or neglected to child protection authorities, be it the police or social welfare officers.
However, it is not mandatory to report elder abuse.
The World Health Organisation defines elder abuse as a single or repeated act, or lack of appropriate action, within any relationship where there is an expectation of trust which causes harm or distress to an older person.
Although under-reported, a study by Dr Sajaratulnisah and her colleagues in UM reveals an alarmingly high prevalence of elder abuse in Malaysia: up to one in 10 cases in urban areas and one in 20 cases in rural communities.
The Prevent Elder Abuse and Neglect Initiative (Peace) is a multi-disciplinary study by researchers from the university’s medical and law faculties which aims to measure and document incidence of elder abuse, determine risk factors, study the consequences and formulate strategies to deal with the issue.
Point of access
Doctors and nurses play an important role in identifying abuse and neglect among the elderly. Because they provide continuing medical care for their patients, primary care doctors have a record of a patient’s medical history.
This is even more so for elderly patients who go for regular follow-ups or have age-related chronic illnesses.
“The very nature of primary care is extending health care from womb to tomb. Primary care doctors and nurses would have built a level of trust with their patients and would be familiar not only with the medical history of the elder patient but also to some extent the dynamics of the family. This makes it easier for them to identify signs and symptoms early.
“For example, if a patient is not taking her medication regularly or has not been coming for their scheduled appointments, the doctor would investigate further and find out why.
“Or if a patient has been coming too often … this may be a sign that they are seeking attention and the doctor could also investigate further,” shares primary care specialist Dr Fadzilah Hanum Mohd Mydin.
For her thesis, “Responding to Elder Abuse and Neglect: A Qualitiative Study on Perceptions and Barriers in Management”, she interviewed 10 primary care doctors to gather their perceptions and experiences of elder abuse and neglect.
All 10 reported that they had come across patients with signs and symptoms of either abuse and/or neglect.
They were unsure of how they should respond, and relied on their own judgements in handling elder abuse cases.
Some referred the patients to social workers or psychologists for emotional support, and some warded the suspected elder abuse victims to temporarily remove them from harm.
“While their experiences differed, all of them highlighted the need for training to identify elder abuse and strategies to manage suspected victims,” shares Dr Fadzillah.
Based on these findings, Dr Sajaratulnisah and Dr Fadzilah ran workshops on dealing with elderly abuse under the Peace initiative for 360 doctors and nurses in Negri Sembilan.
The 10 doctors who participated in Dr Fadzilah’s survey also brought up other elder abuse issues they faced, such as how to broach the topic of abuse with elderly patients and how far should they go in their questioning.
“These are all real problems. But as health care providers, doctors should have a high index of suspicion. We trained them to detect signs symptoms of elder abuse. Physical signs are easier – fractures and bruises, especially in abnormal places.
“But there are other signs to look out for, such as if the elderly persons were malnourished or dehydrated, do they have multiple pressure sores which indicate neglect, are they depressed, anxious or afraid and timid.
“Are their caregivers doing all the talking? Are they defensive?” explains Dr Sajaratulnisah.
It gets complicated when elderly patients have problems with their memory and are not able to speak for themselves. Most patients tend to minimise the abuse or brush the abuse aside. As such, doctors can look out for their welfare in other ways, such as scheduling home visits or more frequent appointments to keep an eye out for them, adds Dr Sajaratulnisah.
“We sometimes forget that the elderly have rights and we cannot decide for them what they should do. Doctors need to discuss with the elderly patients what they want to do.
“In most instances, the patients would not want to report the abuse because the perpetrators are their family members or children.
“Some may be embarrassed to talk about the abuse while others fear that making a report might provoke further abuse,” Dr Sajaratulnisah points out.
Time to Act
Healthcare practitioners’ efforts to address elderly abuse also need to be supported with the appropriate legislations.
The elderly are currently protected under the Domestic Violence Act 1994 (defined under “incapacitated adults”) and the penal code.
But the dynamics of elder abuse are different and require their own unique approach. The definitions of abuse that fall under the DVA are also not applicable in most cases of elder abuse, says UM’s law lecturer Assoc Prof Dr Jai Zabdi Mohd Yusoff.
“We don’t see so much physical abuse when it comes to the elderly. But neglect is one of the most common forms of mistreatment when it comes to the elderly and this is not clearly defined under the DVA.
“The types of protection that the DVA accords abused spouses such as the Interim Protection Order or Protection Order may not be so applicable when it comes to an elderly victim of abuse,” says Dr Jai.
It is high time the country draws up laws that cater specifically for the elderly, says Assoc Prof Dr Siti Zaharah Jamaluddin, also from the law faculty.
“As far as we know there have been no reported cases of elder abuse under the DVA. Perhaps it is because the term ‘incapacitated adults’ is unclear after all, not all elderly people (who experience abuse or neglect) are incapacitated,” she points out adding that the lack of awareness about elder abuse is another reason it stays under the radar.
By 2030, 15% of our population will be over 60. We’re fast becoming an ageing population and we need to prepare for this.
“We need legislation that can support our aging society,” stresses Dr Siti Zaharah who started researching specific laws for the elderly in 2010 after attending a seminar organised by the Attorney General’s Chambers on the topic.
Various stakeholders were invited to brainstorm and discuss details involved in the creation of specific laws for the elderly. Some progress was made but two years after the seminar, the project came to a standstill.
“The AGC at the time thought it was necessary to come up with a statute for the elderly. We had several workshops right up until 2012 and then everything came to a halt. It was the time of the 2013 General Elections and I suppose the AG Chambers was inundated with election cases and this was not a priority.
“We have tried to revive the discussions but everything is at a standstill,” says Dr Siti Zaharah.
Dr Siti Zaharah and Dr Jai have been identifying the gaps in existing laws related to the elderly for the past five years.
They have also looked at legislations for the elderly in several other countries to come up with recommendations to amend and strengthen laws to protect the elderly in Malaysia. Laws for the elderly also have to cover areas like employment, health and the environment
Apart from implementing laws that safeguard the welfare and interests of the elderly, there should also be programmes to integrate the elderly in society.
“One thing that all the elderly told us when we spoke to them (in the course of our research) was that nobody listens to them.
“It is as if once a person retires, the community doesn’t see them as being able to contribute anymore. Like they have nothing more to give. We need to change this perception,” says Dr Siti Zaharah.
One way, she suggests, is by introducing programmes that integrate retirees back into society, either through programmes in school or part-time hire.
“They have a wealth of knowledge and experience. Why not bring them into schools and let them share their experiences with the students – they can talk about a period in history where they actually experienced, for example,” suggests Dr Siti Zaharah.
To mark World Elder Abuse Awareness Day which falls on June 15, the Prevent Elder Abuse and Neglect Initiative (Peace) of the Julius Centre, Universiti Malaya will be holding a series of activities at the Universiti Malaya Medical Centre concourse from June 13–17. There will be a screening survey for caregivers, an exhibit (in both English and Bahasa Malaysia) on ageism, elder abuse and neglect and silent witness exhibits which share some real-life stories of elder abuse and neglect.
On June 15, Star2 is organising a free public forum entitled, Seniors Matter: Safeguarding Our Elders with Universiti Malaya’s Medical Faculty. We will be discussing the need to protect and uphold the rights of the elderly, as well as the challenges of caring for senior citizens.
Speakers: Assoc Prof Dr Sajaratulnisah Othman Assoc Prof Dr Siti Zaharah Jamaluddin Dr Farizah Mohd Hairi Old folks home manager Parameswary
Date: 18 June 2016
Time: 9.30am -12.30pm
Venue: Menara Star 15, Jalan 16/11, Petaling Jaya, Selangor
To register, please call Laila at 03-79671388 or go to safeguardingourelders.eventbrite.com/. Closing date: June 15 2016