Institutional Abuse on Elders in the UK - Essay Example

Institutional Abuse on Elders in the United Kingdom 2007 Introduction While child abuse has been a much publicized and talked about issue in most western societies, elder abuse often goes unreported – partly because of lack of understanding of the issue and partly because the elders as well as the caregivers often tend to hide the facts. Many elders are too fragile or embarrassed to report abuse incidents. According to the House of Commons Health Committee (2004), as many as 500,000 elders in the United Kingdom are estimated to be abused at any point of time. Abuse occurs in the home setting as well as in institutions. It is perpetrated by family members, care staff, relatives, friends and the society at large. Abuse may also take many forms – physical abuse, sexual abuse, medical abuse, medical negligence, withdrawal or control of treatment, sedating patients or simply degrading the elderly by treating them in a dehumanized or infantile manner. This paper will discuss the issue of elder (that is people above 65 years of age) abuse in the institutional setting. The demographic factors that make the abuse of elders critical in the United Kingdom will be discussed. The definition of elder abuse is controversial since the case of neglect and deliberate control of medication for elders is often not very apparent. Often, over-prescription is used by the care staff to control elders, particularly those with dementia, in nursing homes. The ethical dimensions of this form of treatment as well as other issues of abuse, like neglect and treating elder patients as if they are kids, shall be discussed. The social factors that lead to such situations as well as the responsibilities of the caregivers, including doctors, nurses and others, shall thereafter be discussed. The ageing population in the United Kingdom The demographics of the United Kingdom have been changing over the years in a manner that the proportion of elderly is increasing. As a result of higher life expectancy at birth as well as above 65 and lower birth rates – at 2.2 per woman – the proportion of the elderly is expected to grow even further (Jeevans, 2004). It is estimated that by 2025, over 30 percent of the UK population will be above the age 55. Not just that, the government projects that as early as 2014, the number of people above 65 will be higher than those below 16. In 1981, the life expectancy of men at 60 was another 16 years while that of women was another 21 years. In 2003, it was 20 for men and 23 for women. The government projects that in 2026, it will be 24 and 27 for men and women respectively (Jeevans, 2004). Source: Jeevans, 2004 According to the International Longevity Centre – UK (2006), the population in the UK and Wales is expected to grow by 6.5 million till 2031, of which 5.6 million will be above 65 years and 2.3 million above 80 years. The south east and north-west parts of the country have the highest number of people above 65 years while the east Midlands and the east are expected to have the highest growth in the number of elders by 2028. Population of England and Wales 2000 2050 Source: International Longevity Centre – UK, 2006 Although the baby boomer generation looks at ageing in a considerably different manner than did earlier generations, with more people above 65 having gainfully employed lives and 30 percent of people above 75 helping out other elderly who are in need (Jeevans, 2004), there are frequent media reports of institutional abuse on the elderly, particularly on those who suffer from dementia or learning disabilities. According to the International Longevity Centre – UK (2006), 1 in 100 people in the UK suffer from dementia. The figure is 1 in 20 for the age group between 70 and 79 years, 1 in 5 for people between 80 and 85 and 1 in three for those above 90. Hence, the issue of abuse takes crucial importance for such elders who are not able to look after themselves. The definition of elder abuse In the “No Secrets” document, the Department of Health in the United Kingdom defined ‘vulnerable elder’ in 2000 as one “who is or may be in need of community care services by reason of mental or other disability, age or illness; and who is or may be unable to take care of himself, or unable to protect him or herself against significant harm or exploitation” (quoted in House of Commons, 2004). The document defines ‘abuse’ as “Abuse may consist of a single or repeated acts. It may be physical, verbal or psychological, it may be an act of neglect or an omission to act, or it may occur when a vulnerable person is persuaded to enter into a financial or sexual transaction to which he or she has not consented, or cannot consent. Abuse can occur in any relationship and may result in significant harm to, or exploitation of, the person subjected to it” (quoted in House of Commons, 2004). According to the guidance, abuse may be physical, sexual, psychological, financial or material, neglect or acts of omission or discriminatory. Physical abuse consists of hitting, restraining, over or under medication. Sexual abuse consists of forcing a person into a sexual relationship without his or her consent. Psychological abuse consists of shouting, swearing or treating a person in a degrading manner. Financial abuse is involved when a person’s money, property or bank documents are illegally accessed. Neglect occurs when a person is deprived of heating, food, clothes or other items of daily care. The guidance has, however, been criticized for considering ‘abuse’ as essentially criminal activities and not incorporating abuse in the form of degrading a person or “inappropriate personal relationships” (House of Commons, 2004). Further, the guideline seems to think that the elders are abused not because of the disadvantage of their age but because they are ‘vulnerable’ and unable to protect themselves. The prevalence of elder abuse There is little academic research on elder abuse in the United Kingdom. The problem is confounded by the lack of social awareness regarding elder abuse and the inadequate training over detection of abuse cases. The most comprehensive study on elder abuse was conducted by Ogg and Bennett (1992) who surveyed a sample of about 2,000 people. They found that about 5 percent of the elders above 60 years of age suffered verbal or psychological abuse while 2 percent suffered physical or financial abuse from family and relatives. In contrast to elder abuse at the family setting found in the above study, a survey by the Community and District Nursing Association found in 2003 elder abuse was as prevalent as 88 percent and 12 percent of elders reported abuse at least once a month (House of Commons, 2004). Concern about elder abuse has existed at the policy as well as the voluntary level in Britain for quite some time. Age Concern England, a voluntary organization raised the issue as early as in 1984. The organization supported the Action for Elder Abuse program as well as the Department of Health’s initiatives. The Social Service Initiative (SSI) found in 1992 that there was insufficient policy to prevent elder abuse in London boroughs (MacCreadie, 1996). Institutional abuse on elders According to House of Commons (2004), 67 percent of elder abuse occurs in own homes while 12 percent occurs in nursing homes, 10 percent in residential care, 5 percent in hospitals, 4 percent in sheltered care and 2 percent in other locations. Although elder abuse was so long considered to be more prevalent in the domestic setting, it is increasingly being recognized that it occurs in the institutional setting as well. The Royal College of Psychiatrists noted in 2000 that “Abuse does not occur in rare, dramatic and well-publicized incidents; it is a common part of institutional life” (quoted in House of Commons, 2004). Older people living in communal settings, by age and gender. Great Britain. 1991. Age NHS hospitals Local authority homes Voluntary/private residential homes Voluntary/private nursing homes Total Men Women Men Women Men Women Men Women Men Women 65-74 5838 6529 5326 7093 7000 10948 6450 10360 24614 34930 75-84 6130 12900 10442 26738 13460 45998 13579 39742 43611 125378 85+ 2362 12013 7388 35463 10855 62835 9377 49680 29983 159991 Totals 14330 31442 23156 69294 31315 119781 29406 99782 98208 320299 Source: Hancock R (1995), Claudine McCreadie (1996) As seen from the above table, there are more women living in institutional setting than men. A large number of such women are also disabled. As found by McCreadie (1996), older women in institutions with disabilities grossly outnumber men in similar stare. Over the past thirty years, the number of institutions for chronically ill and disabled elders has increased hence the need for policy to prevent abuse. Richardson et al (2002) found that lack of education has an important effect on elder abuse in institutions. Abuse persists in these settings because of the absence of protocols in reporting and managing abuse incidents. In an experiment conducted over nurses in a North London nursing home, it was found that 81 percent of the nurses did not know how to detect abuse cases. There is a power imbalance between the caregivers and the elders in care homes that increase the vulnerability of patients. BUPA noted that frail and mentally impaired elders are vulnerable to sexual abuse in care homes. Further, elders with challenged behaviour run the risk of caregivers responding to their needs in an abusive manner. The UK Nursing and Midwifery Council receives on an average 1000 allegations of abuse a year, of which 50 percent of abuse cases are in the nature of physical, verbal or sexual abuse. In the year 1998 alone, 84 nurses were dismissed on such allegations (House of Commons, 2004). However, the issue of elder abuse is increasingly being recognized and a system of detection and regulation is being set up at the institutional level. The National Care Standard Commission (NCSC), an independent body set up under the aegis of Care Standards Act 2000 reported that 50 percent of the 29,000 care homes it inspected had put in place an abuse reporting and detection system. Yet, the Commission received 12,685 abuse complaints, of which 10 percent related to specific allegations while the rest are in the nature of neglect or inadequate care (House of Commons, 2004). NCSC Complaints 2002-03 Types of complaints Number % of total Poor care practices 3,583 28 Inadequate staffing 2,896 23 Other 1,771 14 Abuse 1,278 10 Unsatisfactory premises 991 8 Quality of food 880 7 Poor management 798 6 No leisure activity 488 4 Total 12,685 100 Source: House of Commons, 2004 Specific reports of institutional abuse The Commission for Health Improvement (CHI) inspection in August 2002 found at the Rowan Ward in the Manchester Mental Health and Social Care Trust insufficient system to detect and check abuse on elders. The report concluded: “The Rowan Ward service had many of the known risk factors for abuse; a poor and institutionalised environment, low staffing levels, high use of bank and agency staff, little staff development, poor supervision, a lack of knowledge of incidence reporting, a closed inward looking culture and weak management at ward and locality level” (quoted in House of Commons, 2004). CHI also reported its investigation into the North Lakeland NHS Trust, which has had history of abuse reports since 1996 when five nurses at the Garland Hospital alleged physical abuse on patients. The allegation was dismissed after an enquiry but in 1997, the ward was merged with two other that had patients with disabilities and behavioural challenges. In 1998, there were complaints of physical abuse in this ward as well. An external investigation was conducted and it was found that “degrading – even cruel practices” (quoted in House of Commons, 2004) were meted out to patients by some staff. Among the cruel practices, the report noted the following: a patient was tied to the commode to prevent violent behaviour and some were fed while sitting on the commode, some patients were not given the food as other patients while others were not provided with clothes and blankets. The report also noted that although similar cruel treatment was reported in 1996, nothing was done about it (House of Commons, 2004). In 2002, the CHI found that the Gosport War Memorial Hospital did not have guidelines for prescription of pain-relieving drugs as a result of which there was excessive prescription for the older patients. Besides a proper supervision and appraisal system of prescriptions, the trust also lacked a multidisciplinary patient assessment procedure (House of Commons, 2004). The Tizard Centre of the University of Kent reported in 2006 that the elders – particularly women living in care homes and those suffering from dementia or other long term illness - are most vulnerable to abuse in the United Kingdom. Older people with mental illness are vulnerable to different types of abuse, according to the survey. In the institutional setting, elders are likely to be abused by the care staff. What is more shocking is that elders who have mental disabilities are more likely to be subject to sexual abuse. Although people who live in out-of-area locations are more prone to abuse, the existence of an adult protection coordinator is seen to make a difference. The survey examined local authority databases covering 6100 people over 1998 to 2005 (Kent, 2006). There have been frequent media reports on abuse of elders in nursing homes. For example, in 2001, 84-year old Katherine Barnes was sexually abused by John Tiplady, the owner of the expensive Denison House nursing home in North Yorkshire where she was a resident. She was too frail and her Alzheimer’s Disease was too advanced for her to report the abuse (Hill, 2001). Types of abuse Anti-psychotic drugs: In many institutions, excessive medication, especially of the anti-psychotic type, are used for people with dementia to make it easier for the staff to control them. Such drugs calm and pacify patients. Between 1999 and 2002, British doctors wrote 6 percent more prescription of anti-psychotic drugs in the United Kingdom (House of Commons, 2004). Typically, in nursing homes, patients are either over-prescribed or under-prescribed such drugs since they do not have the capacity to verbally respond. Many of the care staff are not adequately trained to understand the requirements of anti-psychotic drugs. The Alzheimer’s Society told the House of Commons (2004) that “Over-prescription of neuroleptics is a common form of physical abuse – often used to sedate people with dementia in care of homes or hospitals”. Although anti-psychotic drugs are at timed required to calm patients with dementia, these are more often used to prevent patients from wandering away or unruly behaviour. Burstow (2002) found that among the 935 resident patients in 22 south London nursing homes, 24.5 percent were prescribed such drugs, of which 82 percent was not appropriate. Physical restraint: Besides anti-psychotic drugs, many institutions also attempt to restrain elders by using furniture like bedrails or ‘Buxton’ chairs, physical confinement or electronic tagging, which are all the more terrible (House of Commons, 2004). Such restraint mechanisms, which may as well result in physical injury, are criminal and should never be indulged in by nursing homes. Inappropriate medication: In the United Kingdom, it has been seen that nearly 7percent of the hospitalisation of patients are for medication and about two-third of such medication can be avoided. Elders are more vulnerable to morbidity as a result of inappropriate medication. Older people in nursing homes are prescribed more drugs than those at home and the number of hospital admissions as a result of medication is nearly four times that of others. The National Survey Federation (NSF) has advocated a special medication guideline for older people. Yet, only 44 percent of UK nursing homes meet the standards of medication guidelines. Many of the inappropriate medication can even end up being fatal (Howard and Avery, 2004). Neglect: Elder abuse may also be in the form of neglect and unavailability of items of daily need like heating, food or even teeth. Forced isolation and lack of leisure activities are also forms of institutional abuse of elders (Penhale and Manthorpe, 2001). Dehumanization: Whether abuse amounts to physical abuse, deliberate neglect or ignorance, in all situations, in all cases elders are dehumanized. Institutional abuse of elders occurs in a set-up of power imbalance where doctors and nurses yield power over the patients. Surveillance: The French philosopher, Michel Foucault described how patients, elderly, madmen and criminals are subjected to the disciplinary gaze of the authority. In the care management of the elderly, in particular, it has been found that the evolution of bio-medicine and the clinical definitions of decay have imposed a disciplinary condition on the geriatrics. Informal, residential and community care of the elderly have put them under surveillance of the care managers. In order to reduce the minimum number of service providers as well as costs of care management, surveillance techniques are increasingly being used to monitor the medical state of the elderly even before they are admitted to the institutions. Not only do social service departments monitor the health status of the elderly, the community and the various organizations entrusted with funding of social security are also engaged in the process of scrutiny. Training of care givers Institutional abuse of elders is mostly as a result of insufficient training of the paid staff. Till recently, caregivers were not provided with training to deal with elder patients. The General Social Care Council has recently issued the Codes of Conduct and Practice to be followed by caregivers. Training is required not only for best practices to be followed for care but also for detecting cases of abuse. Various initiatives have been taken up, like the multi-agency awareness programs in Surrey (House of Commons, 2004). Doctors as well as nurses need to be trained to prevent and report elder abuse (Garner, 2002). It is often the case that even doctors carry their beliefs on old age into their profession. Conclusion The United Kingdom is increasingly becoming an ageing society as a result of high life expectancy at birth as well as above 60 and of low birth rates. While many of the elders above the age of 65 are capable of taking care of themselves, a large number of the elders are dependent on care either in the residential setting or in institutions. Elder abuse at the institutions is becoming a worrying phenomenon that made the House of Commons undertake a study of the situation. It was found that very little formal research has yet been done regarding elder abuse in the United Kingdom. However, anecdotal references and sample surveys point out to the fact that institutional elder abuse, though less than that in homes, is not insignificant. In particular, elder people suffering from dementia and other behavioural and mental deficiencies are subject to physical abuse like excessive prescription of anti-psychotic drugs, inappropriate medication, physical restraints and neglect. Although financial abuse of elders may not be as rampant in the institutions as in the residential setting, incidents of sexual abuse of elders have been reported from some care homes. Most institutions do not have systems to detect and prevent abuse. In particular, paid staff are not trained to prevent and detect abuse. Doctors, on the other hand, assume a particular quality of life for the elders and may adopt inappropriate treatment procedures. On the whole, elders face a dehumanized situation when they are assumed to be “less than full persons” and treated accordingly. Works Cited Jeevans, Christine, Welcome to the Ageing Future, 29 November 29, 2004, BBC Online, http://news.bbc.co.uk/1/hi/uk/4012797.stm International Center for Longevity – UK, Building Our Futures, Planning for an Ageing Population North East HLIN 2006, Retrieved from www.ilcuk.org.uk House of Commons Health Committee, Elder Abuse, Second Report 2003-04, 2004, retrieved from https://www.kcl.ac.uk/kis/schools/life_sciences/health/gerontology/pdf/elderabus/intro.doc Ogg, J and Bennet G, Elder Abuse in Britain, British Medical Journal, Vol 305, 1992 Kent, Tizard report advances knowledge and understanding of the abuse of vulnerable adults, December 8, 2006, http://www.kent.ac.uk/news/stories/article-current.php?id=tizardreport.txt Age Concern England (1986) The law and vulnerable elderly people. Age Concern England. London Social Services Inspectorate, Department of Health (1992) Confronting elder abuse. 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