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Older people abuse: how nurses can spot the signs and what to do about it

It is vital that nurses recognise abuse, be it physical, emotional, financial or sexual, and take action

It is vital that nurses recognise abuse, be it physical, emotional, financial or sexual, and take action

  • An estimated one in five people over 65 has experienced abuse, the charity Hourglass says
  • Older people can be victims and perpetrators of abuse in any setting, including care homes and their own homes
  • Community nurses must consider all elements of peoples lives that might be affecting their health

Abuse of older people is at unprecedented levels but nurses across settings are in a key position to help those at risk.

As many as

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It is vital that nurses recognise abuse, be it physical, emotional, financial or sexual, and take action

  • An estimated one in five people over 65 has experienced abuse, the charity Hourglass says
  • Older people can be victims – and perpetrators – of abuse in any setting, including care homes and their own homes
  • Community nurses must consider all elements of people’s lives that might be affecting their health
Picture shows nurse talking to a masked older woman
Picture: iStock

Abuse of older people is at unprecedented levels but nurses across settings are in a key position to help those at risk.

As many as one in five people aged 65 and over has experienced abuse, whether physical, emotional, financial or sexual, says the charity Hourglass, which obtained responses from 2,505 people in a survey last June.

But in spite of the prevalence of abuse there can still be challenges in recognising it or knowing what to do when you suspect it is happening, some nurses say.

Queen’s Nurse Rosy Watson
Rosy Watson

‘It’s almost a taboo subject,’ says Queen’s Nurse Rosy Watson, clinical leader of a community nursing team.

Domestic violence isn’t acknowledged as happening with older generations

‘There aren’t the conversations about it in the same way as child abuse is discussed and is featured on television. Also, domestic violence isn’t necessarily acknowledged as something that happens with older generations as well.’

Older people can be victims – and perpetrators – of abuse in any setting, including care homes and their own homes, says Ms Watson, who works for Norfolk Community Health and Care NHS Trust.

‘In practice, the role of the community nurse is to walk into all of these environments with their eyes and ears open.

Many members of the public unsure about what constitutes older people’s abuse

‘We’re not just there to do a task, we’re not just there to do the nursing care. We’re there to consider the other elements of their lives that might be impacting on their health.’

‘Are prescriptions being picked up, delivered and requested regularly? If the amount requested is not as it should be, then check what is happening’

Mary Harrington, consultant geriatrician and Hourglass trustee

Last year, Hourglass – formerly known as Action on Elder Abuse – published the results of a survey suggesting that around 2.7 million older people in the UK had been affected by abuse, but that many members of the public were unsure about what constitutes abuse.

Key findings from Growing Old in the UK survey by Hourglass

Hourglass logo

  • More than one in five (22%) of 2,505 people in the UK either had personal experience of abuse as an older person (aged over 65) or knew an older person who had been abused
  • More than half (53%) felt that abuse and neglect of older people had increased as a result of lockdown
  • Attitudes towards what counts as abuse are thought to be fuelling the crisis, with one in three believing that inappropriate sexual acts directed at older people do not constitute abuse
  • Nearly one third (30%) don’t see pushing, hitting or beating an older person as abuse, and 32% do not see taking precious items from an older relative’s home without asking as abuse

(Hourglass (2020) Growing Old in the UK 2020: Understanding the Abuse of Older People)

Launching a campaign called Safer Ageing Week, the charity warned of the shocking scale of abuse and said that for many it had become even more acute in the pandemic.

 Hourglass trustee Mary Harrington
Mary Harrington

Hourglass trustee Mary Harrington, a consultant geriatrician for many years and now semi-retired, says abuse can happen in any setting, and nurses working in all environments should be aware of the signs.

She said: ‘I would hope all nurses in emergency departments would have finely tuned antennae and some good clinical skills in recognising what might be accidental issues and what might be inflicted injuries, for example.’

Bruises are a particular case in point, says Dr Harrington. Clinicians should be able to recognise patterns of bruising that are a result of the ageing process and changes in the skin caused by medications, but they should also be able to identify those injuries that are out of the ordinary.

‘We need to report this, and not just at a safeguarding level – it may be a matter for the police,’ says Dr Harrington. She says medication abuse is also a key area.

Spotting the signs of abuse

What to do if you suspect abuse

Trust your instincts iconTrust your instincts and your clinical experience. If something doesn't feel right explore it further or make time to return to have that conversation

Check with your patient/service user in private whether there is anything that is bothering them or making them feel unsafe, and be prepared to return to the topic if they don't feel comfortable disclosing anything initially

Signs of abuse, bruising, iconBe aware of signs such as unexplained bruising, bruises in odd places (soles of feet, genitals, buttocks, neck, ears) or medication discrepancies that could show someone is being intentionally over- or under-medicated

What to do if a patient or service user discloses abuse

Document iconDecide if the person is safe in that moment – if not, explain that you want to ensure their safety and that you want to get help. Document the conversation securely. Don't confront a suspected abuser

Organisation's policyHave a quick look at the organisation's policy and contact arrangements to make sure you know what is expected of you – this may be to contact the safeguarding lead or duty manager

A carer might over-medicate to try to keep someone quiet or asleep, for example, or might withhold medication to exert control over someone. Dr Harrington gives an example of a case in which she was involved where a man with Parkinson’s disease was left immobile because his wife would not give him essential medicine on the days when her boyfriend was coming to the house.

‘He was stuck in his chair while his wife and her boyfriend were in the bedroom next door,’ she says. This was spotted because the man also had diabetes and it was noted at the day hospital that his blood sugars were erratic because of the way his medicines were being administered.

Prescription drugs could be disappearing into the illegal substance community

Other signs of medication abuse could be related to prescriptions, says Dr Harrington.

‘Are prescriptions being picked up, delivered and requested regularly? If the amount requested is not as it should be, then check what is happening. Is it not being given, and therefore the next request doesn’t come in soon enough?

‘Or are rather more of the codeine, tramadol and fentanyl patches being requested – are the transdermal opiate patches “coming off in the shower” too often to be creditable, because there are drugs that may be of interest to the extended household and may be disappearing into the illegal substance community.’

RCN professional lead for older people and dementia care Dawne Garrett
Dawne Garrett

RCN professional lead for older people and dementia care Dawne Garrett says abuse does not disappear for either victims or perpetrators as people age or experience worsening health conditions.

Nurses are often poor at recognising older people as perpetrators of abuse

She says people may have lived with abuse and in abusive relationships for years, and if they become more unwell their ability to mitigate that abuse or remove themselves from situations can disappear, making the abuse much worse.

‘We are poor at recognising older people as perpetrators. As nurses we find that hard to consider. So when we are doing an assessment of an older person we don't think: “Are they a perpetrator of abuse? Are they continuing in sexual abuse of people, do they still engage in domestic violence? Are they emotionally abusing their partners?” We often think about older people simply as the recipient of abuse, not the perpetrator.'

Nurses are trained to recognise abuse, she adds, and the RCN has published guidance on safeguarding, including specific information on adults. But nurses can also be unintentional perpetrators.

‘One of the things we’re clear about in the safeguarding framework is that we have to recognise our own ability to demonstrate abusive characteristics,’ says Dr Garrett.

‘I’m not particularly talking about the extremes of physical or sexual abuse, but about the ways in which we might disempower people because of our processes.

‘As healthcare workers in whatever setting, if you’re trying to do things too quickly, if you’re trying to do things without enough staff, it’s easy to disempower people who have a high level of need.’

If someone discloses abuse, nurses should listen and document what is said

Helping someone to dress at an outpatient appointment could be the perfect time for them to talk if they were experiencing abuse, she says.

‘You’re in a relatively intimate situation, it’s a safe hospital environment, it’s the perfect opportunity to say: “Is everything all right, do you feel safe, is anything making you feel unsafe?”

‘But if you’ve got another 15 people in the waiting room, all of whom require help dressing and undressing, it’s less likely you’re going to facilitate that interaction because you’re pressured, and the person you’re caring for knows that you’re pressured.’

If someone does disclose abuse, nurses should listen, she says. ‘Don’t make any promises that you’ll keep it a secret, or that sort of thing. Make no promises, but arrange for further investigation through your safeguarding policies.

‘The best thing you can do is listen and document what they have said to you, verbatim, then whatever your local safeguarding policy says in terms of recognition and reporting.’

Cover of Hourglass's Challenge The Unthinkable campaign booklet

In Norfolk, Ms Watson’s team comes together weekly to raise any concerns they might have about a particular situation.

‘We’re not necessarily talking about raising an escalation to the safeguarding team, but we would have a conversation to highlight awareness about a particular case,’ she says.

Nurses should be professionally curious, have an open mind and be courageous

‘These conversations are held as a team. It’s about being professionally curious, about having an open mind, and it’s about being able to feel courageous enough to either open up a conversation with the person you think might be being abused, but equally being courageous enough to come back to the team and say this doesn’t feel right.’

She gives the example of an older woman who had been left severely incapacitated after surgery and was receiving wound care at home.

‘As the weeks went on and we established a bit more of a comfortable relationship within the home, her partner no longer felt the need to be with her all the time when we were there,’ explains Ms Watson.

‘That was when she started speaking to us about his controlling behaviours, and saying that she didn’t want him to live there. He was controlling the money, the shopping – and wouldn’t buy the things she wanted or needed – was being verbally abusive to her, being derogatory to her in front of the nursing staff, and being intimidating.

‘She was terrified and disempowered and isolated but she didn’t think she could manage without him, so she wasn’t able to ask him to leave.’

‘We reported everything – even our medication errors went to safeguarding – and I do think that’s the way forward’

Sandra Blades, member of RCN Older People’s Forum

This situation was witnessed by different members of the community nursing team. They escalated it to the trust safeguarding team, who supported them with a referral to the local multi-agency safeguarding hub. This encouraged the patient to seek help from a domestic abuse charity, and to source support from social work so that she felt able to ask him to leave.

Masked older women talking to masked nurse
Picture: iStock

‘The reason we were going in was because she had a post-surgical wound,’ says Ms Watson. ‘But the role of the community nurse is to go in and look at the whole picture.’

Care homes should be transparent and engage with local safeguarding processes

The National Institute for Health and Care Excellence is expected to publish guidance on safeguarding adults in care homes this month.

RCN Older People’s Forum member Sandra Blades says it is important for homes to be transparent and engage with local safeguarding processes.

‘Nurses certainly have a duty of care to identify and report any concerns. In care homes, safeguarding and safeguarding training is paramount for staff. From my personal experience of working in care homes, if in doubt, and no matter what the situation was, it was reported to safeguarding.

‘That builds up bridges between all the organisations. We reported everything – even our medication errors went to safeguarding – and I do think that’s the way forward.’

Dr Garrett says every interaction with a patient or resident is an opportunity for them to speak, and it might be the first time they have spoken out. ‘We are hugely trusted as nurses and we should be using that status to the best effect to help the people we are caring for.’


Find out more

Hourglass (2020) Winter Elder Abuse Warning

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