Coordinated Community Response Agreement

Abuse and Neglect of Older Adults

In Peterborough County and City

Support for this project has been received under the National Crime Prevention Strategy of the Government of Canada

Acknowledgements

We gratefully acknowledge the generosity of many other elder abuse prevention networks that willingly shared their community protocols. These documents were used as a basis for discussion and development of this Coordinated Community Response Agreement. In particular, special thanks go to the following:

• Arlene Groh and the Waterloo Region Committee on Elder Abuse
• Lisa Manuel and the Family Service Association of Toronto
• Sheli O’Connor and the Wellington Dufferin Seniors Services Network
• Carolyn Cybulski Rocco Martone and the Elder Abuse Prevention Committee of Sault Ste, Marie & Area, and
• Seniors Resource Centre Association of Newfoundland and Labrador

We also acknowledge the Government of Canada’s National Crime Prevention Centre – Community Mobilization Program, and the City of Peterborough and local organizations for their financial assistance. Without this support the development, printing and distribution of this Coordinated Community Response Agreement, the education of professionals, agency staff and volunteers, and public awareness campaigns would not have happened over this past year.

The Peterborough Community Access Centre generously provided not only office space but also administrative support, supervision and a welcoming, generous place to work.

Thank you to Karen Clarke and Beth Steinmiller of the Abuse Prevention of Older Adults Network for their direction and encouragement, and to Joanne Preston, Regional Consultant for the Ontario Strategy for the Prevention of Elder Abuse for her expertise and reliable response to requests for feedback.

In addition, I would like to express my sincere appreciation for the editing of the document by Merriam and Associates, the administrative support provided by Melody Burnstad, and Christine Tomkinson, and the personal support freely given by Ann McLeod, Gloria Edwards, Dawn Berry Merriam, Emi Embri and Gail Grant.

Most especially, gratitude goes to those members of our community who provided input, encouragement and guidance and became engaged in the process of this project, including the following:

• Ann McLeod, Peterborough County City Health Unit
• Barbara Hetherington, Community Health Services, Canadian Red Cross
• Bob Geddes and Shirley Geller, Canadian Association of Retires Persons
• Brad Tucker, FourCAST Addiction Services Team
• Janet Bolger and Suzanne Turk, Veterans Affairs Canada
• Catherine Johnston, YWCA Peterborough
• Nancy Lewis and Chad Kelly, Alzheimer Society Peterborough
• Danielle Belair, Community Care Peterborough
• Dawn Berry Merriam, St. Joseph’s at Fleming
• Dianne Austin, Community Living Peterborough
• Doreen Anderson-Roy, Victorian Order of Nurses
• Emi Embri, Capacity Assessor
• Gail Grant, Psychiatric Assessment Services for the Elderly, Peterborough Regional Health Centre
• Gloria Crowley, Compliance Advisor Ministry of Health and Long Term Care
• Heather Karkheck, Kawartha Sexual Assault Centre
• Janet Duke, Victim/Witness and Assistance Program
• Jean Lush, St. John’s Anglican Church, Ida
• Jeanette Cruikshank, HRDC Social Development Canada
• Jenny Ingram, Geriatrician
• Joanne Shadgett, Salvation Army Parish Nurse
• Kerri Davies, Royal Gardens Retirement Home
• Kim Heise, Community Counselling and Resource Centre
• Merrill Graham and Robert Donovan, Telecare Peterborough
• Cathy Pappas, Office of the Public Guardian and Trustee
• Fraser Wilson and Pauline Chaggares, OMNI Health Care
• Pina Melchionna, Scotia Private Client Group
• Ray Vandervelde, Peterborough Lakefield Community Police Service
• Roberta Citro, Canadian National Institute for the Blind
• Ron Hancock and Janice Scott, Peterborough Housing Corporation
• Gerry Smith, Ontario Provincial Police, Kawartha Detachment
• Beth Steinmiller, Peterborough Community Access Centre
• Susan Cumming, Adult Protective Services
• Murray Lincoln, Northview Pentecostal Church
• Shirley Shaw, Activity Haven
• Joanne Preston, Ontario Strategy for the Prevention of Elder Abuse
• Mark Graham, Canadian Mental Health Association
• Bobbi Martin Haw, Peterborough Regional Health Centre
• Susan Czestiakow, Canadian Hearing Society

Helen Perkins, Coordinated Community Response Project Coordinator

Abuse Prevention of Older Adults Network

August 24, 2005

Table of Contents

Acknowledgments

Executive Summary..................................................................................................... i

Chapter One - The Agreement................................................................................... 1

Chapter Two - Older Adult Abuse............................................................................. 6

Chapter Three -Confidentiality................................................................................. 19

Chapter Four - Guidelines for Assessment................................................................ 25

Chapter Five - Capacity.......................................................................................... 41

Chapter Six - Guidelines for Responding.................................................................. 49

Chapter Seven - Police Response............................................................................ 59

Chapter Eight - Abuse and Neglect in Facilities........................................................ 65

Chapter Nine - Documentation................................................................................ 69

Chapter Ten - Appendices ...................................................................................... 71

Appendix One - Community Resources................................................................... 72

Appendix Two - Safety Planning.............................................................................. 76

Appendix Three - P.I.E.C.E.S................................................................................. 78

Appendix Four - Assessment Guidelines.................................................................. 80

Appendix Five - Who assesses Capacity.................................................................. 83

Appendix Six - Consent and Capacity Board........................................................... 86

Appendix Seven - Power of Attorney Job Description.............................................. 88

Appendix Eight - Types of Intervention.................................................................... 90

Appendix Nine - Decision Tree................................................................................ 92

Appendix Ten - History of Abuse Prevention of Older Adults Network.................... 93

Appendix Eleven - Terms of Reference.................................................................... 98

Appendix Twelve - Recommendations for Evaluation............................................. 100

Appendix Thirteen - Bibliography and Resources................................................... 101

Executive Summary

Background

A network was established in Peterborough County and City in1988 around the goal of preventing and eliminating abuse and neglect of older adults. One of the factors driving this initiative was demographics. For the last two decades, Peterborough County and City have had the third highest percentage of older adults in the province. Founding members of the network consisted of older adults, professionals and agency representatives.

From the beginning this network believed that education, awareness and a coordinated community response were needed to achieve their goal. By the end of the 1990’s, a community forum organized by the network determined that dedicated staff was needed to move the issue forward.

In 2001 the network, now know as the Abuse Prevention of Older Adults Network (hereafter called the ‘Network’, or APOAN) successfully applied for a grant to hire a coordinator to raise awareness about the issue of older adult abuse through education of all sectors including faith communities, financial institutions, police and the legal sector, health and social service professionals and workers, educational institutions, and volunteers, and to conduct public awareness campaigns.

In 2004, another grant was successfully acquired for a project coordinator to work with the community to develop a coordinated response. This Coordinated Community Response Agreement (from here on referred to as the Agreement) is the product of that effort.

From the beginning of the development of this coordinated community response, there was an inclusive invitation to all interested organizations and professionals to participate. The project coordinator met with the executive personnel of most key organizations that work with older adults to explain the grant and goal of the project. An invitation to participate resulted in approximately fifty attendees to the first meeting on December 22, 2004. Forty different organizations continued providing input into this Agreement during the subsequent months of its development. This interest reflects the perceived need on the part of those who connect with older adults for more effective ways of addressing older adult abuse in our community.

The Coordinated Community Response Agreement and the Process to Develop It

This Coordinated Community Response Agreement is a description of how our community has agreed to work together to address abuse and neglect of older adults. The purpose of this Agreement is to provide a common accountability framework that guides an inclusive network of community organizations, professionals, and others in Peterborough County and City in providing a coordinated, client-oriented, rights-based approach that is inclusive of the victim, and deals with the root cause and effects of the abuse or neglect.

Our work begins from the position that abuse is an issue of power and control. This implies that the best framework for working to prevent and respond to instances of mistreatment is one of empowerment.

Throughout the period of the grant, education sessions were carried out for volunteers and front line staff of organizations that work with older adults. In addition presentations were conducted for service clubs and other groups, and two public awareness campaigns were achieved with broad media coverage.

The committee that developed the Agreement determined that an interdisciplinary consultation team was needed to provide information about available options for addressing difficult situations of older adult abuse. The model for this aspect of the community’s coordinated response has been determined and a subcommittee is responsible for completing the planning, arranging training for members of the team, and launching and coordinating this interdisciplinary consultation service.

Next Steps Needed for Implementation

At every strategic point along the way, the community (professionals, agencies, APOAN members, and the public) have clearly indicated the need for a salaried, dedicated individual to:

• Support community organizations in implementation of the Coordinated Community Response Agreement
• Inform other organizations who connect with older adults about the Coordinated Community Response Agreement, and invite their participation.
• Provide education to front line staff of all community groups that work with older adults, and
• Coordinate the interdisciplinary consultation team.

There is a need to find stable funding to hire dedicated staff to support the community in addressing older adult abuse – to build on the investment of education, public awareness and creation of this Agreement. This is an issue that affects the whole community and an effective response requires the coordinated efforts of the community.

Coordinated Community Response Agreement

To Address Older Adult Abuse in Peterborough County and City

Introduction

All of us, who work with older adults, need to know about abuse and neglect of this population. We don’t have to be ‘experts’, but we do need to know:

· How to recognize an older adult who may be experiencing abuse

· How to relate to and support an abused older adult

· How to access appropriate community services, and

· What to do in an emergency.[1]

This Coordinated Community Response Agreement (hereafter called the ‘Agreement’) was developed as a project of the Abuse Prevention of Older Adults Network on a one-year grant from the National Crime Prevention Centre – Community Mobilization Program. An inclusive group of community agencies and individuals representing a wide range of sectors from Peterborough County and City came together between December 2004 and July 2005 to create this document.

This Agreement is a description of how our community has agreed to work together to address abuse and neglect of older adults. It is a work in progress, intended to support front-line service providers and management as it . . .

· Offers information about preventing, recognizing, and responding to abuse and neglect of older adults

· Provides a framework and guidelines to help with decision-making

· Clarifies what’s expected

· Contains contact information for community resources

· Helps to reduce anxiety and uncertainty about the consequences of action or inaction.

The Abuse Prevention of Older Adults Network (hereinafter called the ‘network’) intends to review and update the Agreement to reflect new research, expressed needs of those experiencing abuse or neglect, and findings about what works in our community.

How to Use the Agreement

This agreement is intended to be applicable to a wide range of professionals, services providers and community members. For this reason, the document may not always reflect what is expected of you in your role.

Different organizational settings, mandates and professional roles may limit the role you can or should play in identifying and responding to abuse of an older adult. Specific expectations regarding reporting, roles and responsibilities are best defined by organizational or professional protocols.

We strongly encourage all organizations that work with older adults to have a protocol on abuse of older adults that reflects the philosophy and guidelines in the Agreement. Agency and interagency policies, procedures and training are needed to give staff and/or volunteers direction and confidence to recognize and respond to older adult abuse.

If you have no protocol, you can use this Agreement with your particular work and responsibilities in mind.

Last but not least, remember that abuse is complex - there are no easy answers or quick fixes. By working together, each of us in our own way can contribute to helping victims of older adult abuse rebuild their lives.

Note: Wherever in this Agreement the context so requires, the singular number shall include the plural number and vice versa and any gender used shall be deemed to include the feminine, masculine or neuter gender.

Who the Agreement is Intended to Serve

The focus of the Agreement is abused older adults. The Agreement includes younger adults in situations where their vulnerability is due to the aging process. This being said, the protocols outlined within this Agreement can be used by agencies/organizations and individuals in addressing situations of abuse of other vulnerable adults for whom the philosophical framework, guiding principles and resources apply.

Purpose of the Agreement

The purpose of this agreement is to provide a common accountability framework that guides an inclusive network of community organizations, professionals, and others in Peterborough County and City in providing a coordinated, client-oriented, rights-based approach that is inclusive of the victim, and deals with the root cause and effects of the abuse or neglect.

The purpose reflects the fact that adult abuse and neglect is an issue that . . .

· Affects the whole community,

· Can come to the attention of any individual or organization that connects with older adults, and

· Is usually complex and multi-faceted, resulting in a variety of issues that need to be addressed by people with different skills, knowledge and expertise.

Philosophical Framework[2]

Our work begins from the position that abuse is an issue of power and control. This implies that the best framework for working to prevent and respond to instances of mistreatment is one of empowerment. Adopting the power and control model shifts the focus to addressing the issue of domination and subordination.

The approach of this Agreement is a rights-based approach, dealing with causes and effects, and involves:

· Establishing trust

· Taking time, and

· Moving towards long-term improvements for the individual.

The focus is from the abused individual’s perspective, wishes and needs. In some cases, the abusers are not wilfully abusive or neglectful but may lack the knowledge, skills or personal resources that may hinder or interfere with their ability to provide adequate care. Help is available to both the abused and the abuser.

Guiding Principles[3]

The following principles that form the foundation of this Agreement are grounded in an empowerment model. They include the following:

1. Abuse is a complex issue embedded in human relationships. It is an expression of power and control exercised over another person.

2. Every individual has the right to live his/her life free of abuse.

3. Abuse of older and vulnerable adults is a societal problem.

4. It is everyone’s responsibility to end the abuse of older and vulnerable adults.

5. Social change will occur only through education and a comprehensive and diverse community response.

6. All forms of abuse, whether deliberate or inadvertent, are unacceptable.

7. Support, assistance and/or protection offered to each individual should always be in the most effective, but least intrusive form.

8. When addressing possible abuse, all aspects of the individual’s circumstances are to be taken into consideration, including, but not limited to:

· Cultural diversity

· Language barriers

· Religious beliefs

· Lifestyle choices

· Poverty

· Educational background

· Disabilities

· Social supports

· Health status

9. Service providers must be committed to developing and delivering services that meet a diverse range of needs, maximize the options available to older adults, and are responsive to the needs and wishes of the abused person.

10. Until the contrary is demonstrated, each individual is presumed to be capable of making decisions regarding his/her health, personal care, legal and financial matters.

11. A capable individual is entitled to live in the manner he/she wishes, and to accept or refuse support, assistance or protection.

12. When there is reason to suspect that an individual is incapable and at risk of serious personal or financial harm and there is no Power of Attorney or it is not appropriate to involve the attorney named in the Power of Attorney, it is advisable to contact the Office of the Public Guardian and Trustee.

Rights-Based Approach[4]

Early in the work with abused older persons, organizations, professionals and society tended to use a ‘Best Interest’ approach, acting in what they believed was the best interest of the older person. This approach often excludes the older adult and does not deal directly with the abuse or underlying problem. This approach tends to be immediate and short term and create its own abusive dynamic.

This Agreement is based on a ‘Rights-Based’ approach.

It focuses on how the older adult sees the situation.

The approach used in this Agreement is a ‘Rights Based’ approach. This approach deals with causes. It involves establishing trust, taking time, and moving towards long-term improvements. The focus is on how the older adult sees the situation and what actions they want to take.

Rights of Older Adults

Older adults have the entitlement to the following basic rights:

· Self-determination: The right to live their lives as they want and to make decision for themselves, provided that their actions are not against the law or that they do not infringe upon the rights and safety of others. As such, an older person is free to control her/his affairs to the full extent of her/his abilities, including residing at home for as long as possible and the right to refuse assistance, intervention or medical treatment.

· The basic requirements of life: These include food, shelter, clothing, social contact, and medical attention.

· Safe and adaptable environments: Living conditions that are safe and appropriate to personal preferences and changing abilities.

· Informal support: The right to benefit from family support and care consistent with the well being of the family.

· Formal support: The right to access social, health, housing, legal services and any other services necessary to enhance capacity for autonomy and well being. This includes the right to access services, at the same level provided for other age groups, when dealing with the implications of violence in later life.

· Dignity: The right to live in dignity and security and to be free of exploitation and physical, mental or financial abuse.

· Confidentiality: Whatever information a person chooses to share or whatever information becomes known about them remains confidential except in specific situations, as dictated by law (See Section on Confidentiality.)

The Agreement is to be used to assist organizations, individuals and agencies in working together. No one group can do everything and this Agreement allows us to work together in a more collaborative and coordinated way to address older adult abuse.

Older Adult Abuse

How big is the Problem?

Abuse of older adults isn’t a new problem, but our awareness and understanding of it is relatively recent. It was only in the late 1980’s that the first survey was done to estimate how widespread the problem is in Canada (Podnieks, 1989). The national survey of 2000 men and women living in private dwellings, age 65 and older, was conducted by telephone, using a self report questionnaire. The results showed that:

• 4% had experienced at least one form of abuse
• Most common form of abuse was financial.

The survey concluded that different forms of abuse require different intervention strategies.

Other research in the late 1990’s showed the prevalence rate to be10%.[5] Some think even this figure is understated because abused older adults are reluctant to identify themselves. They may be embarrassed, unsure it will do any good, unwilling to risk rejection by loved ones, or afraid of having to leave their home.

Our Aging Community

The 2001 Statistics Canada survey revealed that in Peterborough County and City:

• 29% of the population was age 55 and older (compared to 22% for Ontario)
• 18% were age 65 and older (compared to 13% for Ontario)

Peterborough County is has the third highest percentage of older adults in Ontario, after neighbouring counties Haliburton County and City of Kawartha Lakes. Northumberland County neighbouring Peterborough on the south and east is fourth.

Baby Boomers, those Canadians born between the end of the Second World War and the mid-sixties, represent the largest age group in our population. One in every three Canadians is a Baby Boomer. In 2005, Baby Boomers are those aged roughly 38-57 years. Given that age 55 is used as the definition of an older adult[6], over the course of the next fifty years the sheer numbers of older adults will demand that needs of older adults become a much more urgent issue. By implication this would include enhancing our ability to provide information and support to prevent and address older adult abuse.

This is a complex issue that involves the whole community, including all cultures and faiths, men and women, and all groups, organizations and businesses that are in contact with older adults. There are no ‘simple solutions’ and it will take public awareness, education and a coordinated community response to prevent and address the issue effectively.

Types of Abuse, Indicators and Potential Responses[7]

Types

There is general agreement on types of mistreatment of older persons. There are also several indicators that are useful in the identification of potential abuse. The following are not legal definitions; rather, they are intended to help people in the community and professionals working with older people to recognize abuse.

Indicators

It is important to note that indicators of abuse are only indicators. Listen to the explanations being given, but challenge them if what you are being told is not consistent with what you are observing. No one indicator of abuse is definitive proof that abuse exists; instead, a clustering of indicators makes abuse more likely. Don’t jump to conclusions. At the same time, don’t ignore your gut feeling that something is amiss. Instead, gather more information.

Responses that build trust

Any ‘intervention’ with an abused older person must be one that gives control and confidence to (i.e. empowers) the older person. This involves actively listening to and respecting their wishes, providing information about their rights and options, and supporting their decisions. All of these behaviours help to build trust – trust needed if the older person is going to reveal to you what is happening and make changes to improve their situation. The most important skill you have to support an abused older adult is your ability to listen. The questions and responses below are only suggestions to be used as an adjunct to personal and professional skills. Also see Chapters on Assessment and Responding.

When asking questions, talk to the older person (alone); don’t rely on the explanation of others. Use non-threatening words and questions. Observe closely and focus on the unmet needs of the abused older person. Avoid blaming anyone – this closes the door to further information and help. Blame, guilt and shame are barriers to disclosure.

Type of Older Adult Abuse	Abusive Behaviours Include but are not limited to:	Indicators of Abuse Include but are not limited to:	Potential Questions	Potential Response Options
Physical: any act of violence or rough treatment causing injury or physical discomfort	· Rough treatment, pinching, squeezing, pushing, jerking · Hitting, kicking, slapping, throwing objects, choking · Burning, shaking, twisting · Confinement, restraining, use of weapons · Deliberate misuse of medication, including over medicating and withholding medication · Attempting to apply force or threatening (by act or gesture) to apply force to an individual in such a way that the individual can ‘reasonably’ expect the threat or action to be carried out	· Unexplainable physical injuries such as burns, bruises, lacerations, fractures repeated falls, rope marks, swelling, symmetrical grip marks · Injury for which the explanation does not fit the evidence · Delay in seeking treatment · Injury to scalp, evidence of hair pulling · Pain or discomfort or signs of under medicating · Appears ‘drugged’, unusually lethargic or shows other signs of over medication · Claims of being ‘accident prone’	· I see you have _____ (describe injury e.g. bruises, cuts). This type of injury causes me to wonder if someone has hurt you. · It is natural for people to get into arguments. Does this ever happen to you? What happens when you argue with ________ (suspected abuser)? · Has anyone tried to hurt you? · Has anyone ever hit, slapped, restrained or hurt you or threatened to? · Does anyone pull your hair? · Have you ever been forced to eat (force-fed)?	· Provide information to the older person about the following: o That what is happening is not their fault; that many older people experience this mistreatment by family members; and that there are people who can help them find ways to stop the mistreatment o That abuse escalates over time and without some kind of action it’s unlikely to stop o That safety planning is necessary to keep them safe when the abuse happens again (See Safety Planning in Appendix) · Carefully document where injuries were observed, including size of bruises, colour and location. The use of a body chart and/or pictures that are dated and signed can help guide this process if appropriate. · Document explanations the older person gives for injuries observed. · Help the victim create a safety plan (See Appendix : Safety Planning) · With the older person’s permission, involve police. · Refer the older person to a medical professional for a full medical evaluation.
Sexual: any sexual behaviour directed towards an older adult without that person’s full knowledge and consent (does not include touching, remarks or behaviour of a clinical nature that is appropriate to the provision of care)	· Inappropriate sexual comments or jokes · Jealousy · Unwanted or uncomfortable touching or kissing · Withholding sex or affection · Forcing person to strip or pose for photos · Promiscuity · Demanding or forcing intercourse with self or others · Sexual assault, sexual harassment	· Pain, bruises, bleeding in genital area · Difficulty in walking or sitting · Genital pain, itching or infections · Rope marks or other signs of physical restraints · Inappropriate or unwanted sexual behaviour or comments	· Does anyone make lewd or offensive comments to you? · Does anyone approach you in a way that causes you to feel uncomfortable? · Has anyone touched you sexually without your permission? · (If yes) Is there a risk that you have contracted a Sexually Transmitted Disease (STD) or HIV/AIDS?	· Provide information to the older person about the following: o That what is happening is not their fault; that many older adults experience this mistreatment even by family members; and that there are people who can help them find ways to stop the mistreatment o That abuse escalates over time and without some kind of action it’s unlikely to stop o That safety planning is necessary to keep them safe when the abuse happens again (See Appendix: Safety Planning) · Communicate that any form of sexual touching is wrong when a person does not explicitly consent to it. Saying ‘no’ means ‘no’. Inability to say ‘no’ does not mean ‘yes’. Only saying ‘yes’ means ‘yes’. · If appropriate, recommend contacting the Women’s Health Care Centre, family doctor, or hospital emergency department for medical care including testing for sexually transmitted diseases, HIV, or collection of forensic evidence with the older adult’s consent. · If appropriate, suggest they receive supportive counselling and attend a sexual assault care centre · Encourage/assist with safety planning to keep them safe when the abuse happens again (See Appendix : Safety Planning)
Financial: the misuse of an older person’s funds and assets; obtaining property and/or funds without that person’s knowledge and full consent, or in the case of an older person who is not mentally capable, not in that person’s best interests; or misuse of Power of Attorney for Property	· Withholding money · Critical of parents spending choices · doling out older person’s money, withholding, or providing small sums of ‘allowance’ · Using older person’s resources, (e.g. food, alcohol) without payment or permission · Using funds and assets for ones’ self · Overcharging for services · Unpaid loans or repeat borrowing · Obtaining property and funds without the person’s knowledge and full consent, or in the case of a vulnerable person who is not competent, not in that person’s best interests · Forced changes of a will · Forcing, compelling or coercing an older person to sign over Power of Attorney or give them money or possessions · Theft of older person’s money or possessions	· Abuser believes that older people do not need money nor have a future · Unexplained or sudden inability to pay bills, account withdrawals, changes in will or Power of Attorney, or disappearance of money · Refusing to allow older person to spend their own money without approval of abuser · One person insists on handling or controlling finances · Withholding financial information · Refusing to use older person’s own money for things the older person needs or wants · Moving in or not moving out of older person’s residence against their will · Lack of money – unexplained discrepancy between known income and standard of living · Loss of assets, disappearance of possessions · Property sold without older person’s permission · Older person has signed a document (e.g. will, property deed, power of attorney) without full understanding	· How do you feel about the way your Power of Attorney for Property is being used to make decisions on your behalf? · Do you control your own finances? If no, who does? How come? · Does anyone in the family depend on you for shelter or money? · Have you ever been asked to sign banking papers you don’t understand? · Have you ever given your bank card and personal identification number to someone and they have not returned it?	· Provide information to the older person about the following: o That what is happening is not their fault o That many older adults experience this mistreatment even by family members; and o That there are people who can help them find ways to stop the mistreatment o That abuse escalates over time and without some kind of action it’s unlikely to stop o That safety planning is necessary to keep them safe when the abuse happens again (See Appendix: Safety Planning) o The older person has the right to make decisions about how their money is used o Use of their money or property by someone else without their express permission is not legal o The process for changing a power of attorney and the advisability of using a lawyer to do this · Help the older person consider the implications of not taking action · Let the older adult know about options and ask how you can help · Options could include revoking Power of Attorney, counselling; alternative housing; possibly additional financial support; legal help, involving the police
Emotional: any act which diminishes an older person’s identity, dignity, or self-worth	· Insults about older person · Overly familiar (e.g. ‘dear’) – not using name the older person prefers · Habitual verbal aggression, name calling · Withholding affection, shunning, ignoring as punishment · Treating older person like a child or questioning their competency · Humiliating in private · False accusations · Expecting older person to look after grandchildren when beyond their wishes or ability · Threatening to put older person in a ‘home’ · Removal from decision-making · Repeated humiliation in public · Alienating family and friends · Misuse of Power of Attorney for Personal Care · Threats of violence or retaliation	· Fear · Low self-esteem · Extreme passivity · Older person appears nervous when suspected abuser present · Resignation, withdrawal or depression · Anxiety · Loss of decision-making ability · Social isolation · Missed or cancelled appointments · Individual with older adult is verbally aggressive, insulting or threatening towards older person · Individual with older adult shows unusual amount of concern (too little or too much); speaks on behalf of older person; does not allow older person to make decisions; is reluctant to leave older person alone with professional or others · Sudden/unexpected decline in health of the older person	· Do you sometimes feel nervous or afraid? · Does anyone call you names or insult you? · Are you able to freely communicate with your friends and/or other family members? · You seem tired; are you getting enough sleep? · Are you often yelled at by someone? Who? What do they say? · Does anyone threaten or intimidate you? Who? What do they say or do? · Who makes decisions about your life, such as how or where you will live? · Can you tell me on a scale of one to ten how you would rate your self-confidence, if one is very low and ten very high? · Has anyone ever threatened to send you to a nursing home? · Has anyone ever threatened to send you back home (i.e. country of origin)? (ask when applicable) · Does anyone ever tell you that you are no good? · Are there times when you think of harming yourself? (If so, determine risk. Is there a plan or is it a fleeting thought?)	· Provide the older person with information about the following: o That what is happening is not their fault; o That many older people experience this mistreatment even at the hands of family members; and o there are people who can help o That abuse escalates over time and without some kind of action it’s unlikely to stop · Reinforce that name calling, threats, etc. are wrong · Tell the older person that such behaviours are the perpetrator’s attempt to control them · Ask the older person about their wishes and what is important · Provide options and ask the individual how you can help · Let the older person know the benefits of and offer supportive counselling · Work with the individual on ways to respond to demeaning messages from others · If threatening or harassing phone calls are being made, advise the person to keep a log of date, time, content and who called (if known). Let them know this kind of behaviour is illegal and discuss benefits of involving the police. · If letters or emails are sent, advise the older person to keep copies of them
Neglect: deliberate or thoughtless failure to meet the needs necessary for the older person’s physical and mental well being; may be passive neglect due to lack of experience, information or ability	· Failure to provide adequate o Food o Clothing o Shelter o Medical care including medication o Hygiene o Social stimulation	· Unkempt appearance – dirty or inappropriate clothing · Malnourished, dehydrated · Missing dentures, glasses, hearing aid · Missed or cancelled appointments · Unattended for long periods · Hypothermia: shivering, bluish tinge · Untreated medical problems · Confined to bed, chair, room or house · Fridge and cupboards have little or no food · Is frail or cognitively impaired and presents alone or without regular caregiver	· Are you getting all the help you need? · Do you have anyone living with you? · Do you have anyone to help you with _____ ? · Ask about existence of health care aids (e.g. hearing aids, walker, cane) · Who makes decisions about what help you receive? · Do you get out or have people who drop by or phone you during the day or week?	· Provide information to the older person about the following: o what is happening wrong and not their fault; o many older people experience this treatment at the hands of family members; and o there are people who can help them · Let the older person know they have a right to: o Live in conditions that are safe and sensitive to their abilities and needs o The basic requirements of life like food, shelter, clothing, contact with other and medical attention o Accept or refuse help · Ask the older person about their wishes and what is important · Provide options and ask how you can help · Options could include counselling; in-home support through the Peterborough Community Access Centre or other local agencies; supportive housing; legal help or additional financial support
Denial of Civil Rights: denial of a person’s fundamental rights (according to the Charter of Rights and Freedoms/ Declaration of Human Rights)	· Denial of privacy · Withholding information · Denial of visitors · Denial of independent legal advice · Mail censorship · Restriction of liberty	· Restricted access – difficulty visiting, calling or otherwise contacting older adult · Older adult makes excuses for social isolation · Inability to express opinions or vote · Not allowed to attend faith or social gatherings · Isolation	· Are you free to come and go as you wish? · Do you have easy access to the telephone? · Does anyone open your mail without your permission? · Are you able to speak to your lawyer or doctor in private? · Are you involved in decision making about things that affect you in a way that meets your satisfaction?	· Provide information to the older person about the following: o what is happening wrong and not their fault; o many older people experience this treatment at the hands of family members; and o there are people who can help them · Let the person know they have a right to: o privacy & confidentiality o decide who they will or won’t talk with or see o where they go or who visits o how they live provided it doesn’t endanger others or themselves o refuse assistance and intervention o participate in decisions about themselves in accordance with their ability to do so

Barriers to Disclosure – Why Older Adults are Reluctant to Talk about Abuse

Older adult abuse and neglect is known as a ‘hidden crime’. The following are some explanations as to why abused older adults may be reluctant to disclose that they are being mistreated:

• Fear of exposure, family honour, embarrassment, shame
• Fear of more abuse
• Loss of the abusive person from their life
• Fear of institutionalization
• Lack of awareness about what constitutes abuse
• Parental roles – guilt, concern for abuser
• Family break-up is unacceptable
• Lack of self-esteem and assertiveness
• Believe “I deserve what I get”[8]

Risk Factors

Who is at Risk of Being Abused?

Any older adult can become a victim of abuse or neglect. Older persons of all ages, cultures, faiths, religions, women and men, independent and dependent can experience mistreatment at the hands of family and those they should be able to trust.

One study[9] concluded that many issues previously found important in identifying cases of abuse were not validated. Contrary to past theories, the physical or emotional impairment of a care recipient or the need of a care recipient for a great deal of help with activities of daily living does not signal risk of abuse. Nor does a situation in which a caregiver is under great stress and strain. These are important problems that may well require help and professional intervention, but are not abuse markers and should not be a focus in specifically abuse-centred assessments and interventions.

This being said, there are factors that seem to put older people at higher risk of abuse.

Current literature suggests that older persons are at higher risk when . . .

• Over age 75
• Cognitively compromised
• Female
• Single or widowed
• Living with family
• Victims of past abuse
• Socially isolated
• A history of family conflict.

Who is at Risk of Becoming Abusive?

Statistics Canada 2004 reports that abusers of older adults are more likely to be family members, particularly those who are financially dependent on the older adult, including spouse, adult children, grandchildren, and other relatives who are close to the older adult.

Isolation[10]

It has been noted that isolation seems to be the single largest factor contributing to abuse of older persons. Isolation implies a lack of physical contact with the outside world. It also manifests itself in emotional isolation due to a lack of contact with supportive persons, and is often accompanied by constant verbal putdowns that result in low self-esteem.

As a society, we may have inadvertently contributed to the isolation of some older adults. Factors that interfere with people gathering together easily include the fact that families often live at great distances; families are often so busy and stretched financially that these distances make ‘being there’ rare; some rural community buildings have been closed; and the layout of urban areas and reliance on the automobile require that older adults be able to drive.

To off set this, programs that link and support older adults, such as Wheels to Meals, Friendly Visiting, reassurance calls, Telecare, various faith and seniors groups, adult day programs, all play an important role in reducing isolation and the risk of abuse for older adults.

Indicators and Contributors to Isolation

One of the most significant means of active engagement in society is the telephone, particularly for older adults who may not have the transportation or mobility needed to get together with others. Isolation can result when the older person lacks access to the telephone.

The following are some observations that may indicate that the older person is being restricted from accessing the telephone:

· The older adult never answers the phone

· The older adult cannot access the answering machine

· The telephone is placed out of reach of the older adult

· The ringer is turned down or phone jack pulled out of the wall

· Call screen is in place and family, friends, etc. are being screened out.

Other indicators that the older person’s access to others is being restricted include:

· Appointments are frequently cancelled

· Necessary appointments (i.e. medical, renewing medications at the pharmacy) are not made

· Someone talks over the older adult

· Necessary health-care aids are denied or not in easy reach (e.g. hearing aid, glasses, false teeth, cane, walker, and wheelchair).

Isolation can result when the older adult speaks a different language or has speech or hearing difficulties that interfere with communication

In some cultures, lack of access to the remote control to see TV programs in the language of choice are factors in isolation and abuse.

Assessing for Isolation

Some questions that might indicate whether or not isolation is contributing to abuse of an older person are:[11]

· Are you alone a lot?

· Has anyone ever refused or not been there to help you take care of yourself if you needed it?

· Do you get to see your friends and family often?

· Do you feel isolated?

· Are you allowed to make decisions for yourself?

· Are you being deprived of contact with others?

· Does anyone accuse you of things that are not true?

· Do you have access to a phone?

· Do you have access to transportation?

· Can you phone anyone you want to phone?

Confidentiality

This is not a complete discussion on confidentiality. For the purposes of this Agreement, confidentiality is defined as follows:

Importance of Confidentiality

Confidentiality is essential for safety of the older adult, and for the establishment of trust – a key factor in helping the older person. If an abuser learns that a victim of older adult abuse has talked about their situation, there is significant risk of retaliation. Peterborough and area is a community in which there are many connections and revealing details of a situation, even without disclosing a name, can breach confidentiality and put the older person at risk.

Trust and Confidentiality

A trusting relationship with an abused older adult plays an important role in achieving a positive outcome. If there is not trust, the older person is unlikely to feel safe enough to disclose information important to finding workable options.

Tips for building trust and facilitating communication:

· show respect

· sit at eye-level

· remain non-judgemental

· listen to the message

· offer options, not advice

· follow the older person’s directions and pace

· be honest, and

· respect confidentiality.

Breaching (what a client understands to be) confidentiality effectively breaks trust. Offering information about confidentiality can build trust. So, whenever possible explain to the older person early in your relationship about their right to confidentiality and the limits on client confidentiality (for instance, reporting lines within an agency; being legally required to report certain types of harm or activities).

Ask the older person if you can talk to others who may be able to help the situation. Many service providers fear breaching confidentiality, but never ask the older adult about it because they assume the client won’t give permission. In many cases, the older adult is agreeable if given support and reasonable explanations about the need to share the information.

If the older person refuses to give permission to disclose information about the abuse, it can be helpful to explore in a gentle way their reluctance so you can either ease the person’s fears or offer other ways of addressing the problem. (See Chapters4 and 5: Guidelines for Assessment and Guidelines for Responding.)

Personal Health Information Protection Act

Health Care providers have always had an obligation to maintain confidentiality. Privacy legislation gives the individual rights related to how his or her personal health information is collected, used and disclosed. On November 1, 2004, the Personal Health Information Protection Act (PHIPA) came into force in Ontario.

Some professionals may have duties about confidentiality that do not apply to other people and some agencies may decide to have more stringent rules about confidentiality over and above any legal standard are required by professional standards.

Purpose of This Law

· Sets out the rules that health care providers must follow when collecting, using and sharing personal health information

· Gives clients the right to request access to their personal health information, the right to request corrections, the right to complain to the Information Privacy Commissioner about refusal to access, and the right to complain to the Information Privacy Commissioner about any breach of PHIPA.

Who the Law Applies to

This legislation applies to individuals and organizations involved in the delivery of healthcare services. Health information custodians are holders of personal health information (i.e. hospital, community care access centres). Employees of health information custodians are referred to as ‘agents’ of the health information custodians. The Act regulates how health information custodians and their agents may collect, use, retain, transfer, disclose, provide access to, and dispose of the client’s personal health information.

Health Information Custodians include:

· Healthcare providers such as doctors, nurses, dentists, psychologists, social workers, optometrists, physiotherapists, chiropractors, massage therapists, dieticians, naturopaths and acupuncturists

· Hospitals, Long-term care homes and homes for special care, Community Care Access Centres, Pharmacies, medical laboratories, local medical officers of health, ambulance service, community mental health programs, and the Ministry of Health and Long-Term Care.

What does the Law Require?

This legislation requires that health information custodians:

· Collect only the information needed to do their job

· Collect, use, or disclose a client’s personal health information only if the client has given consent to do so, or if the Act allows this without consent

· Take steps to safeguard individual’s personal health information

· Take reasonable steps to ensure health records are accurate, complete and up-to-date for the work being done

· Take reasonable steps to protect information that is transferred to others (for example include privacy clauses in contracts)

· Provide a written description of information practices, a privacy contact person, and procedures for access, correction, inquiry and complaints about your personal health information

· Identify the purposes for which personal health information is collected, used and disclosed

· Train staff, volunteers and others acting on the health information custodian’s behalf to follow the information practices and procedures.

Client Rights

This legislation provides clients with the right to:

· Give permission (consent) to how their personal health information is collected, used and shared

· Request access to their personal health information/records

· Request corrections

Clients have the right to complain to the Information and Privacy Commissioner of Ontario if they think their rights have been violated.

Types of Consent

The Act (PHIPA) allows for two kinds of consent:

· Implied consent: The Act permits healthcare providers to assume implied consent to collect, use or disclose health information with other healthcare providers who are involved in a client’s care unless the client states otherwise. For example, when a physician refers a client to a specialist, he or she will assume that permission is given to share the client’s health information with the specialist – unless the client specifically refuses. Health information custodians are required to post notices describing why they collect, use and disclose PHI, and to inform clients that they can withdraw consent for implied consent.

· Express consent: In certain situations health care providers are required to request the client’s consent – orally, in writing or electronically – before sharing that individual’s personal health information. For example, if a healthcare provider is asked to disclose personal health information to someone who is not a healthcare provider under PHIPA, like an employer, express consent must be obtained[12].

The “Circle of Care”[13] is a term used in PHIPA. It is used to describe health information custodians and their authorized agents who are permitted to rely on an individual’s implied consent when collecting, using, disclosing or handling personal health information for the purpose of providing direct health care.

For example, in a physician’s office, the circle of care includes: the physician, the nurse, a specialist or other health care provider referred by the physician and any other health care professional selected by the patient, such as a pharmacist or physiotherapist;

• In a hospital, the circle of care includes: the attending physician and the health care team (e.g., residents, nurses, technicians, clinical clerks and employees assigned to the patient) who have direct responsibilities of providing care to the individual.

The circle of care does not include:

• A physician who is not part of the direct or follow-up treatment of an individual;
• A medical officer of health or a board of health;
• An evaluator under the Health Care Consent Act, 1996;
• An assessor under the Substitute Decisions Act, 1992; and
• The Minister, together with the Ministry of Health and Long-Term Care.

(Personal Health Information Privacy Act (2004) OHA hospital privacy toolkit can be located at: www.ipc.on.ca. Go to publications. It can be downloaded or copies ordered through Ontario Hospital Association website. Refer to page 51, 52, and 53 of the toolkit for 'circle of care' information.)

Consent and Form 14 Changes

As of November 1^st 2004, the Personal Health Information Protection Act (PHIPA) amended the Mental Health Act (MHA) by repealing the access to and correction of clinical record provisions, repealing certain clinical