Prevention and Management of Elder Abuse

Abstract

With the increase in life expectancy, there has been an increase in the proportion of older persons. However, over the years, the importance of elderly people in society worldwide has been declining. In fact there is an alarming increase in elder abuse and neglect. The number of reported cases is only the tip of the iceberg. There is an urgent need to prevent and manage this abuse of the older population. Different strategies have been adopted by various countries. The strategies vary with the cultural background and political set-up, but the basic principles remain the same. There is a dire need to have a strong policy and framework for the implementation of the laws and programmes related to abuse. Training of the elderly, professionals dealing with them and the awareness of the society at large are some of the immediate interventions required. Coordinated multiple agency support is required to implement the same. Research is another component that is required to support the proposed strategies and look for meaningful solutions. Query ID="Q2" Text="Please provide author biography and photos." The different strategies followed in the different countries for the prevention and management are discussed in this chapter. It is the need of the hour that a multi-pronged approach to the problem be adopted for an active and healthy ageing of our population.

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Introduction

Elder abuse is defined by the World Health Organization (WHO) as a ‘single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person’ (World Health Organization, Geneva 2008).

Abuse is a global phenomenon which occurs irrespective of religion, gender, culture and economic status of the society. Ageing may trigger an additional risk of abuse due to the increased dependence on others, social isolation and frailty that accompany it (World Health Organization, Geneva 2008). Abuse, especially of older persons, may not come to light because the symptoms can be confused with changes brought about by ageing. Another reason why abuse or neglect may go unnoticed is that sometimes elderly people choose not to report it because of family pride or self-blame. Moreover, older men and women come from generations that avoided discussing private issues. As a result, elder abuse continues to be a taboo, mostly underestimated and ignored by societies across the world (World Health Organization, Geneva 2008).

Prevalence rates/estimates do not exist in all countries and have so far generally been restricted to a few developed nations. Where there are prevalence studies on elder abuse, rates range between 1 and 35% (Pillemer and Finkelhor 1988; Ruiz Sanmartín et al. 2001; Yan and Tang 2001) depending on definitions and survey and sample methods. These figures, however, may represent only the tip of the iceberg, and some experts believe that elder abuse is under-reported by as much as 80%. Estimates of the number of elder abuse cases reported by other studies range from 1 in 15 cases to 1 in 6 cases. The rates in all these studies are relatively low, and more proactive studies are required to find the real incidence. These low rates may be due to the isolation of older people, the lack of uniform reporting laws and the general resistance of people—including professionals—to report suspected cases of elder abuse and neglect. In developing countries, although there is no systematic collection of statistics or prevalence studies, crime and social welfare records, journalistic reports and small-scale studies provide evidence that abuse, neglect and financial exploitation of older people appear to be widely prevalent (World Health Organization, Geneva 2008).

Except for census enumeration, the government of India lacks collection of information on factors related to elderly people such as prevalence and incidents of elderly abuse and neglect. HelpAge India in its report (Soneja 2011) on elder abuse in India presented statistical data on the distribution of abuse in major cities in India. It discussed the types of abuse in the different cities, the responses of the elderly to abuse and their perception of the laws, policies and role of police and lawyers.

The advocacy work done by the International Network for Prevention of Elder Abuse (INPEA) and the emphasis given to elder abuse prevention by the WHO have contributed significantly to raising worldwide awareness of elder abuse. Academic institutions around the world have also substantially contributed to enhancing understanding and raising awareness. and have developed methodological tools to study the problem. However, much is still to be done (World Health Organization, Geneva 2002b).

Causes and Risk Factors

Before we talk about prevention and management, it is important that we discuss the causes of abuse. There are not many research studies done on this. Also the causes will vary according to social strata. For example, issues pertaining to property are generally seen as the major cause for elder abuse in developing countries. In the developed countries the causes may relate more to the isolation of the older generation. Older adults frequently find themselves mistreated in various ways by people they trust, with significant, lasting consequences (World Health Organization, Geneva 2015). The following list gives some of the causes in the Indian context. It is important to focus here on the causes which result in a multiplier effect on the actual/reported cases of elder abuse.

• 1. Changing family structures and the position of the elderly

  Elderly people are slowly losing their position of authority in the family. Their views are usually not asked and their interference is not welcome and often rebuked. The moving-out of the younger generation and development of nuclear families often leave the elderly isolated in the place of family roots, and hence they suffer neglect. Erosion of family bonds and a history of abuse or violence in the family are risk factors which increase the chances of abuse.

• 2. Deterioration of the physical and mental health of the elderly

  With the increase in life expectancy and longevity, the number of dependant elderly is increasing. The physical and mental ailments make seniors more prone to abuse as their ability to defend themselves is reduced.

• 3. Care-giver’s stress

  The increasing burden of caring for the elderly can result in physical and mental strain. These can at times be expressed in the form of violence or neglect, thus giving rise to abuse. The stress of care-giving can be increased by other stresses on the care-giver, deriving from time constraint, work or family, for example.

• 4. Psychopathology of the abuser

  Various psychological factors such as personality disorders, mental disorders, alcohol or drug addiction can increase the chances of elder abuse, as can low moral values.

• 5. Attitude of the elderly towards abuse

  The elderly may not report abuse, which in turn increases the abuse.

• 6. Other miscellaneous factors

There could include:

• non-availability of framework for out-of-court settlement

• lack of professional counselling

• non-enforcement of serious penalties

• lack of monitoring and reporting by the local police

• absence of police departments specifically for elderly people similar to the ones available for women, children, economic offences etc.

Effect of Abuse

The WHO, in its 2002 policy framework (World Health Organization, Geneva 2002b), mentioned that elder abuse is a violation of human rights and a significant cause of injury, illness, lost productivity, isolation and despair.

The global response to elderly abuse and neglect in the WHO 2008 Report (World Health Organization, Geneva 2008) observes that elder abuse has serious consequences for the health and well-being of older people and can be of various forms: physical, verbal, psychological or emotional, sexual and financial. It can also simply reflect intentional or unintentional neglect. Abuse and neglect are culturally defined phenomena that reflect distinctions between value standards and unacceptable personal behaviour.

Studies have found that older people perceive abuse under three broad areas: neglect (isolation, abandonment and social exclusion), violation (of human, legal and medical rights) and deprivation (of choices, decisions, status, finances and respect) (World Health Organization, Geneva 2002c).

Signs and Symptoms of Abuse

The signs and symptoms of abuse depend upon the type of abuse. Some are listed below.

• 1. Physical

  • signs of injury which cannot be explained, such as cuts, bruises, fractures

  • injuries in different stages of healing

  • overdosage of drugs or missing dosages

  • delay between the occurrence of injury and reporting

• 2. Emotional

  • signs of insecurity and psychological disturbance, like thumb sucking, rocking

  • abusive behaviour of the abuser witnessed by the doctor

  • depression, confusion, fearfulness

  • sudden change in behaviour or alertness

• 3. Sexual

  • bruises around genitals

  • unexplained vaginal or anal bleeding

  • sexually transmitted infection

• 4. Neglect

  • shabby appearance and dirty clothes

  • unexplained weight loss and or dehydration.

Need for Prevention and Management

Prevention and management of elder abuse are of paramount importance, since abuse has an impact on all aspects of a senior’s life, ranging from physical, mental and psychological areas to social, sexual and financial ones. However it is a complex issue and requires a multi-faceted approach. Older persons can themselves be involved in designing programmes to spread awareness and prevent abuse. Besides increasing awareness, some proactive steps need to be taken. Commitment is required at all levels. At the national level, appropriate policy, laws and programmes must be successfully implemented. Action is also needed at the institutional and community level. It is essential for society to become aware of elderly people’s rights and to recognize the existence of elder abuse or neglect. Involvement of the elderly in prevention and management of abuse is an important aspect. Seniors can be empowered with the knowledge of their social, legal and financial rights. It is equally important to focus on the research component associated with the abuse of older persons. Studies are required to look into the causes, risk factors, and the roles of culture and care-givers’ stress, among many other factors.

Global Responses

The Toronto Declaration on Global Prevention of Elder Abuse 2002 (World Health Organization, Geneva 2002d) is a Call for Action aimed at the prevention of elder abuse. This declaration was devised at an expert meeting, sponsored by the Ontario Government in Toronto on 17 November 2002. According to this declaration, elder abuse is a universal problem, prevalent in both developed and developing countries. However, it is more common in high-risk groups such as the very old, women, the poor and those with limited functional capacities. The Declaration advocated primary health-care (PHC) workers playing an active role in the prevention and management of abuse. To prevent abuse there is a need to increase awareness and education about the issue among the general public, media and the professional sector. There is also a need for all countries to provide health and social services, legal protection, police referral, etc., and to appropriately respond and eventually prevent the problem.

The United Nations International Plan of Action adopted by all countries in Madrid (April 2002) clearly recognize is the importance of elder abuse and puts it within the framework of Universal Human Rights. It advocates that everyone should be involved in preventing elder abuse.

The response of different countries (World Health Organization, Geneva 2002) around the world to developing legislation and other policy initiatives is at different stages. Responses at national level use Blumer’s model (Blumer 1971) of social problems to describe progress.

• 1. Emergence of a problem.

• 2. Legitimization of the problem.

• 3. Mobilization of action.

• 4. Formulation of an official plan.

• 5. Implementation of the plan.

The developed countries have a better established system for reporting and treating elder abuse. In countries like the USA and the United Kingdom, there is a national policy in place. On the other hand, countries like Australia and Canada have no national policy, although they have set up systems at the state level and in some provinces. New Zealand has a National Elder Abuse and Neglect Advisory Council, formed in the 1990s, for providing national perspective on strategies for care and protection of older persons. Other European countries (such as France, Germany, Italy and Poland) have activities related to elder abuse and prevention through individual researchers and local programmes. In South America, countries like Argentina, Brazil and Chile have moved on to legitimization and action. However, in countries like Cuba, Peru, Uruguay and Venezuela, awareness of the problem is still emerging. Support services, including a telephone helpline, are available in Argentina. In the Asian countries, researchers have helped to increase awareness of elder abuse in China, Hong Kong, India, Japan etc. The government of South Africa is considering a national strategy on elder abuse.

INPEA, formed in 1997 has representatives from all six continents. It works towards reducing the cases of elder abuse and aims to increase public awareness, education, training and research. It also campaigns on behalf of the abused or neglected people. Its network achieves these objectives by organizing workshops, setting up professional meetings and training sessions, maintaining a website and producing a newsletter.

Role of Professionals and Support Staff

Most elderly people suffer from one or more ailments and come in contact with medical professionals or other health-care personnel. This is an excellent opportunity to detect cases of elder abuse. The elderly place their trust in doctors and are more likely to open up and tell about their abuse. It should be expected that doctors at the PHC level or general practitioners will be able to detect and manage the abuse appropriately. They can address the medical issues and also provide counselling. However, it has been found that they generally hesitate to intervene and prefer to refer the cases to a social worker. Health professionals rarely report cases of abuse (Lachs et al. 1997; Clark-Daniels et al. 1990; Barer 1997).

In a survey (Jones et al. 1997) of accident and emergency ward physicians, it was found that only 31% were aware of a written protocol for elder abuse and most were unfamiliar with the reporting mandates for elder abuse in their state. Surprisingly, only 2% of all elder abuse reports are generated by physicians, despite state-wide mandates in most states (Rosenblatt et al. 1996).

Such inert behaviour could be due to lack of knowledge and training in this area. Another reason could be lack of time due to the heavy caseloads doctors are required to process. Studies have also shown that the various health-care professionals (including doctors, nurses and other staff) feel that they are not qualified or competent to assess the elderly for signs of abuse or neglect (Stotkowski 2008; Wagenaar et al. 2009). In one survey, two-thirds of residency programmes did not place a major emphasis on training about elder abuse (Wagenaar et al. 2009).

Difficulties in the assessment of elder abuse have been studied (Lachs et al. 1997) and include factors such as: (a) no sensitization or training; (b) lack of communication and coordination among the different medical personnel; (c) no set protocols for standard interventions; (d) absence of specific definitions of abuse and its associated terminologies; (e) lack of any social support existing for the care-givers; and (f) no awareness or information available regarding the presence of institutional resources.

However, as mandatory reporters of abuse and neglect, health-care providers have both an ethical and legal responsibility to advocate for victims of abuse by screening, identifying and reporting cases of abuse (Shugarman et al. 2003; Bomba 2006).

It is therefore important that the sensitization of the PHC professionals be increased in all countries around the world. Equally important is the laying-down of legislations and guidelines regarding the management of elder abuse. In a few countries (such as Costa Rica, Kenya and Singapore) legislation does exist; however, it does not cover issues of elder abuse adequately. Brazil has mandatory reporting, but concerns were raised on behalf of PHC professionals who feared for their own safety (World Health Organization, Geneva 2008).

The second important step is to develop PHC professionals’ and social workers’ capacities to deal with elder abuse. Various initiatives have been suggested (Lachs et al. 1997): a few of them are outlined below

• Sensitization of governments regarding issues related to elder abuse. This will enable them to engage PHC professionals, including physicians.

• Medical professionals should be trained regarding detection and management of the abuse. The specific roles of different professionals (such as doctors, nurses and para-professionals) in a hospital need to be outlined.

• Medical professionals must have guidelines regarding appropriate referral of such cases to social workers or other organizations such as non-governmental organizations (NGOs) where proper management of the cases can be done.

• Awareness levels in the community should be increased to help prevent the problem, detect cases, increase reporting and provide support mechanisms.

• Elder people should be informed about their rights, especially in relation to abuse, neglect and exploitation.

• The person abusing the elder, needs also be included in the management plan so that the recurrences do not occur and a permanent solution can be arrived at.

Education of physicians, especially at primary-care level, can increase their competencies in identifying the signs and symptoms of elder abuse.

Some studies based on survey results (Wagenaar et al. 2010) have shown that doctors who have been oriented or trained in the area of elder abuse during their residency, or who have participated in continuing medical education activities, then considered themselves able to detect elder abuse. It is to be wished that such sensitization and awareness regarding elder abuse should be made part of the educational activities in primary care disciplines. The subject should also find a place in general articles, audio tapes and primary lectures (Taylor et al. 2006; U.S. Preventative Services Task Force 2004).

With the advances in technology and the availability of online resources, programmes, massive open online courses (MOOCs) and continuing medical education programmes could also be prepared for physicians (Hill 2005). Jones et al. (1997) found that 92% of physicians surveyed did not believe that their states had sufficient resources to meet the needs of elderly victims; this belief could contribute to reporting apathy.

The physicians have given suggestions regarding the areas to be included in the training programmes. Some of these areas include the law and clarity on reporting procedures (Dumortier and de Freminville 2014). They also desired a requirement to investigate the condition of the patient for possibility of abuse (Lachs and Pillemer 1995; Jones 1990). Abuse should be suspected if a doctor or other health-care worker notices any of the following signs:

• delay in seeking medical attention after an injury or an illness

• history given by the patient is different to that provided by his care-giver or family member

• no definitive explanation of the injury or ill-health by either the patient of the family member or care-giver

• indifferent attitude of the family member or care-giver towards the injuries or the advice given by the doctor

• no care-giver or family member accompanying a functionally impaired elderly person

• laboratory findings inconsistent with the history provided

• worsening of an elderly person’s chronic condition despite diagnosis, provision of a definitive management plan and resources available with the family member/care-giver.

Guidelines need to be drawn up for the doctor or health-care provider to use while examining the elderly person suspected of having been abused (Ansen and Breckman 1988). These could include the following points:

• If the elderly person is physically and mentally able to recall and respond, he should be interviewed alone and not in the presence of the family or care-giver. He should be directly asked about the possibilities of physical violence, restraints and neglect.

• The suspected or implicated abuser should also be interviewed alone to explore the possibilities of abuse.

• The patient’s formal and informal social networks should be explored.

• A comprehensive assessment of the elderly person should be carried out. This would include the medical, functional and cognitive components.

Strategies proposed for involving the health professionals in the prevention and management of abuse in India include:

• incorporation of awareness about elder abuse in the medical and nursing curriculum at undergraduate level

• teaching the skills to recognize and manage (or refer appropriately) cases of abuse during medical training at undergraduate level

• conducting various in-service training programmes for sensitization and training of health professionals in diagnosing and managing cases of abuse, including emergency management of cases due to abuse

• developing online training and the embedding professional education resources about elder abuse into a range of training curricula

• developing treatment protocols and referral strategies for health-care institutions which include government dispensaries, PHCs hospitals and private nursing homes and hospitals.

Care-Givers’ Support Groups

Various agencies also provide support for care-givers. These may offer one or more of the following services:

• providing care-givers as per the requirements

• support through online/social groups

• care-giving training

• medical support

• nursing support

• laboratory support

• nutritionist/dietician support

• physiotherapist or occupational therapist services

• home modification support.

The list of job responsibilities for in-home helpers or care-givers is very long. But they are paid very low wages. Hence, demand for them is much greater than the supply. Due to the low wages, applicants who come forward for care-giving jobs are often individuals with limited alternative employment options. These could include people with limited educational qualifications and training, immigrants, poor language skills etc. In recent years, advocates for elderly and disabled people, unions and workers’ advocacy groups have started working together to call for improvements in workers’ pay and working conditions (Nerenberg 2002a). Through such advocacy, it is hoped that more individuals will enrol and a better service be provided to seniors.

Training of In-Home Helpers

Elderly people with physical and cognitive impairments may require assistance for many activities of daily living. Family members provide this support in most of cases. However, in many countries now, assistance comes from professionally employed in-home helpers who take care of the basic needs of elderly people with dysfunctions. The terms used to describe helpers vary widely and include ‘personal care assistants’, ‘attendants’, ‘chore workers’, ‘in-home support service workers’, and ‘homemakers’ (Nerenberg 2002b). The in-home helpers or assistants may be paid by the person or family employing them or through private insurance agencies. At times they are paid through federal programmes. Agencies which employ them train the in-home helpers with basic skills to care for the elderly. They also orient them towards detecting abuse.

At times agencies may also hire other organizations to train their workers. As part of the training, the workers are given the basic information regarding the common diseases and disabilities affecting elderly people. They are given training on how to manage the daily needs of seniors with various physical and mental impairments, use of their assistive devices, managing their diet and medicine routines etc. They are also trained on how to help elderly people with financial management and shopping, and assist in dealing with banks etc. The most challenging part of the helper’s training is handling the elderly during abusive, violent or abnormal behaviour. Common topics for the care-givers’ programme offered by various organizations include topics like:

• managing activities of daily living

• reacting to emergency situations

• handling injuries and falls

• managing resistance to care

• handling catastrophic or extreme stressful situations

• mastering verbal and non-verbal communication and counselling skills

• managing a bedridden senior

• handling medication errors

• type of help available

• caring for a care-giver

• personal care

• nutrition

• medical aspects of caring

• emotional and intellectual well-being

• legal and financial affairs

• home safety

• when it is time to stop caring

• choosing a residential care facility

• how to work with other professionals and working in multi-disciplinary teams.

Hence, they can observe acts which may be abusive or indicate neglect. Since the in-home helpers are in close proximity to the elders, they win the trust of the senior and be able to discuss private issues with them and help them in abusive situations.

Not all the training programmes touch upon the issues of elder abuse, its identification, prevention or management, but there is an imperative need to do so. The training programmes should empower in-home trainers to:

• identify elder abuse in the families they work with

• protect themselves from being abused

• allay by personal example the general suspicion of helpers as potential abusers.

To develop a plan for elder abuse prevention and management, the following require to be identified at the planning stage:

• the needs felt by the participants

• the background of participants, to customize the training accordingly

• the elder-abuse reporting requirements of the state/country

• a policy which would need to be developed, based on the government’s guidelines for managing abuse

• a procedure which would need to be put in place for handling abuse.

Some of the elder abuse-related areas that should be covered in training courses for in-home helpers might include:

• introduction to the topic of elder abuse (definitions, types, risk factors)

• assessment of abuse cases/recognizing and managing abuse (signs and symptoms of abuse)

• managing difficult behaviour which can give rise to abuse

• behaving in a professional manner

• details of local organizations that can provide assistance

• acquaintance with a standard plan outlined by their organization.

Care-givers’ stress is one of the important risk factors for elder abuse. Research on elder abuse, carried out earlier, was based on the hypothesis that abuse or neglect result from either the stress of caring for a dependent elderly person or lack of relevant competencies and resources (Reingold 2006; Nerenberg 2008). Hence, spreading awareness, educating and training coupled with support programmes are essential components for prevention and management of elder abuse within a care-giving relationship (Wolfe 2003; Ross 2007). Various organizations and agencies thus work towards providing social and emotional support and guidance on how to handle difficult situations, violent behaviour and a potentially abusive environment. This reduces the stress among care-givers and brings down the chances of abuse. A large number of tools are now available by which the care-givers can assess their risks. Care-giver support groups play a multi-faceted role by providing social and emotional support, preparing the care-givers for their intended role, and training them to handle difficult situations (Nerenberg 2008).

Training can reduce the likelihood that workers, themselves, will engage in abusive or negligent conduct. Such components, when included in the training programmes, can help the workers by:

• providing skills to handle difficult situations, e.g. dealing with violent behaviour and learning to defuse potentially volatile situations with confidence

• empowering them to protect themselves from abusive, violent and inappropriate behaviour by their clients

• clarifying their doubts regarding the expectations of acceptable conduct towards clients

• providing them with the knowledge and skills to identify abuse and report it to the appropriate authorities for action

• helping them to handle the stress which is an inevitable part of care-giving

• sensitizing them to the penalties for abuse, and thus reducing the chances of abuse by care-givers.

• keeping their morale high and motivating them to continue the work sincerely even when they get no acknowledgment of the same.

Disturbing behaviours (Nerenberg 2002a) that are frequently encountered by in-home helpers include paranoia, aggression and combativeness. These behaviours are frequently a response to fear, frustration or the inability to communicate. Physical aggression often occurs while workers are providing personal care such as bathing. Tips for reducing disturbing behaviour are:

• maintain patience, avoid anger and reassure the elderly person

• be encouraging and avoid any arguments

• do not use force and avoid negative non-verbal communication

• look for signs of agitation or frustration

• assess situations for danger to self and the care-receiver

• politely refuse interference by other family members in your work

• for any problems outside your control, contact your supervisor.

The workers must practise in professional manner (Nerenberg 2002a). Practice principles give workers the tools they need to deal with difficult ethical situations. These help to keep the agencies and the workers protected from criticisms regarding their role in caring for the elderly. Some of the examples are given below:

• Do not take any money or gifts other than what is your salary.

• Be calm and patient with your client, even if he/she displays unruly behaviour.

• Stay away from, and do not encourage any, sexual advances irrespective of the patient’s physical and mental condition.

• If the patient is uncooperative or does not listen to your repeated requests, report the matter to your supervisor.

The extent to which training interventions with care-givers may reduce the risk of abuse or neglect is still a matter of debate (Nerenberg 2008). Recent research has shown correlations between abuse and higher care burden (Cooper et al. 2009). However, further research is required to assess whether care-giving itself is a potential cause or risk factor for abuse, and the effectiveness of prevention and management of abuse with the help of care-givers (Pillemer et al. 2007).

General Awareness Programmes

Public education and awareness are important for preventing abuse and neglect. The objectives of an awareness programme are to:

• make the general public aware of elderly people’s basic needs

• educate the public about the existence and signs of abuse and negligence, and the risk factors associated with them

• organize sensitizing programmes, workshops, seminars, training programmes etc. with the aim of changing attitudes and behaviour towards elderly people to prevent abuse

• help the public to identify signs and symptoms of abuse, where help can be obtained, and the responsibility of individuals in preventing and reporting elder abuse (World Health Organization, Geneva 2002a)

• promote the development of tolerance among the community towards the demands of elderly people.

The people targeted for these awareness and training programmes include doctors, nurses, other health personnel, police, social workers, legal functionaries, policymakers, educators, researchers, elderly people and the general public. The programmes can be tailored keeping the target population in mind. They can be organized by different governmental organizations and NGOs, self-help and support groups, community centres, resident welfare associations etc.

Awareness programmes should be specific to region and culture. Abuse may be defined differently in different cultures. Non-reporting in different communities could have different reasons, such as seniors protecting their abusers, a sense of shame, stigma etc. Reports in an article on Native Americans in the USA state reveal that among the greatest obstacles to preventing abuse in is the reluctance of elders, their families, tribal leaders and others to admit that abuse is occurring or to seek help (Nerenberg 2004). The participants in a focus group study in South Africa stressed the importance of the media in raising public awareness (Keikelame 2000). Therefore, one must explore the possibilities to promote recognition of the existence of elder abuse and neglect, and the need to detect it, through various workshops for the general public which could be supported by governments and NGOs.

Awareness can also be spread through the social networking sites and media. This will help in changing the attitude of the community towards the elderly. These efforts will be constructive in preventing elder abuse (Srinivasan and Gupta 2015). Qualitative research with abused seniors found that often they are not aware of where to go for help. They also have little or no knowledge of their rights and entitlements. There is an awe of the authorities in general. They are also apprehensive that their issues and complaints may not be taken seriously by the various agencies (Pritchard 2000; Mowlam et al. 2007).

Social Support Services

The existing health and social networks are generally used to provide services to the elderly who suffer abuse or neglect. They mange the cases in a comprehensive manner and generally deal with the medical, legal, ethical, psycho-social, economic and environmental issues (World Health Organization, Geneva 2002d). The support groups often have people in their ambit who have had similar kinds of experiences and hence are able to understand and empathize with those experiencing or recovering from abuse (Nerenberg 2008). Support groups act as a source of affirmation, information and education, creating an empowering environment (Podnieks 1999).

Studies have found that greater social support is independently associated with a lower risk of self-reported mistreatment (Naughton et al. 2010). Those who are abused and have a lower degree of social support are believed to be at a higher level of psychological distress (Fulmer 2005; Dong and Simon 2008; Podnieks 2006). Hence, community-based support groups could be considered as effective interventions for both the abusers and the abused. (Podnieks 1999; Dong and Simon 2008; Hightower et al. 2006).

Telephone helplines to receive reports of mistreatment are often a feature of such systems (Action on Elder Abuse, London 1997; Yamada 1999). These helplines operate in a few European countries such as the United Kingdom, and in local communities in France, Germany and Japan. Programmes in San Francisco and Los Angeles have also experimented with small groups targeting perpetrators and using cognitive behavioural techniques to alter violent behaviour (Bonnie and Wallace 2003). Only the USA and a number of Canadian provinces have created a system solely for handling reports of adult mistreatment.

The concept of emergency shelters and support groups specifically aimed at the elderly has emerged recently. This provides a space where the abused seniors can discuss their experiences with each other. This helps them to build confidence, get psychological support, mange their anxiety levels and allay their fears and doubts. Such emergency shelters exist in Canada, Germany, Japan and the USA (World Health Organization, Geneva 2002d).

Programmes, for preventing abuse of the elderly in their homes, in which older people themselves play a leading role, include:

• developing and offering awareness and training programmes in which the elderly conduct the training programmes of the abused elders

• seniors being involved in providing company to their isolated peers

• setting up community programmes in which the elderly are encouraged to participate

• developing social networks for older people so that they can interact with, confide in and support each other

• establishing social support groups in which elderly people take part as members to help abused seniors to open up, share their experiences more easily, and accept suggestions and management

• creating self-help programmes in local areas to help seniors to become more productive for society, thus building up their self-esteem.

Technology and Assistive Devices

Assistive devices and use of technology to modify the home to suit the needs of the elderly help reduce care-givers’ physical stress. They also improve seniors’ quality of life and thus reduce the possibilities of abuse. Assistive devices include canes, walkers and wheelchairs. Home modification include ramps, broad electricity switches, hand rails, toilet seats at the correct height, proper lighting, bed alerts, fall detectors and door monitors. There are also smart technologies developed for monitoring elderly people and alerting care-givers.

Basic Rights of Elderly People

Older people’s human rights must be guaranteed worldwide (World Health Organization, Geneva 2002a). Some ways in which this could be done are listed below:

• Modifications can be made in the already laid-down laws on domestic and intra-family violence to also cover the elderly.

• Exploitation, abuse and neglect of seniors can be also covered under the existing criminal and civil laws.

• New laws can be introduced by government exclusively to protect older people.

The elderly must be educated regarding abuse, its prevention and management. Some advisory suggestions are:

• Be aware of your rights.

• Plan your future, your daily plan, your contributions towards family and society, your finances and will.

• Be socially active and have your own group of friends and well-wishers.

• Seek out friends, authorities and agencies if you feel you are being abused.

The legal extensions and provisions will help give strength to the existing protective services and increase the number of support groups and other agencies engaged in the prevention and management of abuse, neglect and exploitation of the elderly. There is also a need to safeguard an individual’s right to self-determination. This indicated their commitment to the doctrine of self-determination (Regehr and Antle 1997). The bringing in of resulted in removing a person’s right to make his/her own decisions (Dyer et al. 2005). However, there is also an increasing trend globally to bring in legislative reforms to empower vulnerable adults to play an important role in decision making (Heath and Phair 2007; Donovan and Regehr 2010). Hence a legislative empowerment must be accompanied by the client’s right to self-determination (O’Donnell 2012).

Legal interventions in cases of elder abuse may make use of both the criminal and civil justice system (Kalaga et al. 2007). The improvement in the legislative instruments and training programmes of the legal enforcement and prosecution officers has resulted in an increase in the number of cases of abuse being filed for prosecution (Nerenberg 2006).

The efficacy of criminal and civil justice interventions is also open to debate. A study by Filinson (1993) found that the recurrence rate for abuse was 24% for those who received assistance, support and advocacy in the use of the criminal justice system, compared to just 17% in a control group. In another study, the incidence of recurrence of abuse was unknown in 43% of the control cases compared to just 12% of the intervention cases (Ploeg et al. 2009).

The Indian Scenario

Constitutional and Legislative Provisions

Article 4.1 of the Constitution of India speaks about the well-being of the senior citizen as ‘The state shall, within the limits of its economic capacity and development, make effective provision for securing the right to public assistance in cases of old age’. A few of the major articles and sections of the Constitution of India regarding the elderly are given below (Piyush and Amir 2016):

Article 41 is reinforced by Section 125 of the code of criminal procedure 1973. In this provision, every person having sufficient means is required to provide for his parents who are unable to maintain themselves.

Section 20(3) of the Hindu Adoption and Maintenance Act 1956 makes it obligatory for a person to maintain his aged or infirm parents.

The Maintenance and Welfare of Parents and Senior Citizens Act, 2007 was landmark legislation piloted by the Ministry of Social Justice and Empowerment. It is being introduced by the states and union territories in stages. Under this act, any senior citizen who is unable to maintain himself/herself from his earning or the earning from any property owned by him is entitled to receive relief. Relatives are also bound under this act to look after senior citizens. In case the relief is not provided by their children, grandchildren or relatives, the elderly can seek assistance from the Tribunal constituted under this act to enforce the remedy of maintenance.

Transfer of property to elderly parents from their children is possible if that property was initially passed to the children on condition they would look after their parent(s).

The Code of Criminal Procedure (CrPC), 1973 is a secular law which governs persons belonging to all religions and communities. Daughters, including married daughters, also have a duty to maintain their parents.

The National Policy on Older Persons 1999 (NPOP) (National Policy on Older Persons 1999) was announced by the Government of India in 1999, which was also the UN International Year on Older Persons (National Policy on Older Persons 1999). It helps to assure the rightful place of the elderly in society so that they can lead a life of dignity. The policy also aims to protect the elderly from exploitation, abuse or neglect. It directs the states to:

• provide financial security

• make provisions so that seniors can be provided with shelter, health-care and other needs

• provide opportunities for the development of seniors’ potential

• increase the participation of older people

• provide support services for the elderly

• ensure that the rights of the elderly are not violated

• provide special provisions for elderly females, especially after widowhood.

India as a Signatory to Important International Documents

The Government of India is a signatory to all the following documents (The National Policy of Senior Citizens 2011) and affirms its commitment towards support for older people.

• Proclamation on Ageing and the Global Targets on Ageing for the Year 2001, adopted by the General Assembly in 1992.

• Madrid Plan of Action and the United Nations Principles for Senior Citizens adopted by the UN General Assembly in 2002.

• Shanghai Plan of Action, 2002.

• Macau Outcome Document, 2007, adopted by UNESCAP, which forms the basis for the global policy guidelines to encourage governments to design and implement their own policies from time to time.

The National Policy of Senior Citizens, 2011

In principle, this policy values an age-integrated society (The National Policy of Senior Citizens 2011). It will endeavour to strengthen integration between generations, facilitate interaction between the old and the young as well as strengthen bonds between different age groups. It believes in the development of a formal and informal social support system, so that the capacity of the family to take care of senior citizens is strengthened and they continue to live in the family. The policy seeks to reach out in particular to the bulk of senior citizens living in rural areas who are dependent on family bonds and inter-generational understanding and support.

The National Programme for the Health Care of the Elderly (NPHCE)

NPHCE is an articulation of the government’s international and national commitments as envisaged under the UN Convention on the Rights of Persons with Disabilities (UNCRPD), the National Policy on Older Persons (NPOP) adopted in 1999, and Section 20 of the Maintenance and Welfare of Parents and Senior Citizens Act, 2007, dealing with provisions for medical care of senior citizens (National Programme for the Health Care of Elderly (NPHCE) Operational Guidelines 2011).

This programme aims to provide the infrastructure for the delivery of geriatric care and rehabilitation services right from the tertiary level to the PHC level. It also envisages training medical professionals in post-graduate courses in geriatric medicine and other human resources in geriatric care.

Training of Professionals

In line with the NPHCE, medical colleges have been entrusted with offering post-graduate medical degrees in geriatric medicine. They are required to run geriatric clinics and admit patients in geriatric wards specially created for sick elderly patients. Indira Gandhi National Open University is also offering a postgraduate diploma programme in geriatric medicine which aims to orient practising doctors towards the preventive, curative and rehabilitative management of geriatric patients and older persons. A few seminars and lectures are also held by the various hospitals in this area from time to time.

Training of Care-Givers

There are a number of organizations that are involved in the training of care-givers in general. A certificate course in care-giving programmes is offered by the Rehabilitation Council of India (2017). For over a decade, the National Institute of Social Defence (NISD) (2017) has been actively involved in training in the field of social defence including care of older persons. The Old Age Care Division of the Institute runs a series of programmes/certificate courses.

The Institute conducts the courses by itself and in collaboration with regional resource training centres (RRTCs) and other reputed organizations. There are currently four RRTCs in the field of old-age care, designated by the Department of Social Justice and Empowerment. The long-term, short-term and thematic-based courses that are presently being carried out by the NISD/collaborating organizations are a PG diploma in integrated geriatric care, and certificate courses in geriatric care.

Role of NGOs

Various organizations in India have support programmes for the general public or specific groups. The Agewell Foundation (2017) has undertaken a sensitization and training programme for Delhi Police personnel about older people’s needs and rights in collaboration with Delhi Police. The Foundation has organized a sensitization and training programme at various police stations in Delhi.

Conclusion

Prevention and management of elder abuse is a complex issue and requires a multi-faceted approach. Commitment must be built at all levels. At the national level, policy, laws and programmes are required. The health-care providers need to be sensitized and trained to handle and report abuse. Society at large and elderly people should be made aware of seniors’ rights and recognize the existence of elder abuse and neglect. Seniors can also be involved in designing programmes for spreading awareness and preventing abuse. It is equally important to focus on the research component associated with the abuse of older persons. Ultimately, elder abuse will only be successfully prevented if a culture that nurtures inter-generational solidarity and rejects violence is developed.