Apart from providing appropriate services and care to the elderly persons, elderly care agencies/units should also pay attention to elder abuse and its prevention so as to ensure that the elderly persons could live with dignity. Being the staff members of these agencies/units, how could we identify abusive case as early as possible and what steps should we take to prevent elderly persons from getting physical and psychological harm?

Definition and Types of Elder Abuse

According to the revised Procedural Guidelines for Handling Elder Abuse Cases (Revised 2021) by the Social Welfare Department, elder abuse is defined as follows:

Generally speaking, elder abuse refers to the commission or omission of any act that endangers the welfare or safety of an elderly person. Usually the elderly person being abused and abuser are known to each other, or abusers are responsible for the care of the elderly being abused.

An elder abuse act may occur once or repeatedly, or within a short period or for a long duration. The abusive act itself may constitute elder abuse, regardless of whether the elderly persons consider themselves being abused. Act that may cause harm to the elderly persons, though not being committed intentionally, may also constitute elder abuse.

There are six types of elder abuse:

Type	Nature	Examples of signs / symptoms / behaviours of elder abuse *
1. Physical abuse	It is physical injury or suffering inflicted on an elderly person non-accidentally or due to the absence of any preventive measures.	There are injuries on various body parts of an elderly person, which do not appear to be caused by accident: obvious wounds/ bruises at multiple parts of the body sprains, dislocations of joints and fractures burns/ scalds bruises reflecting the shape of finger, palm and cane lacerations internal injuries An elderly person being abused may exhibit unusual behaviour, such as having uncommon wounds but being unwilling to receive medical examination and treatment, making contradictory statements, frequent wandering around until late at night, in low mood, becoming depressed, becoming passive or being absent from activities in which he/ she used to participate without cause.
2. Psychological abuse	It is the pattern of behaviour and / or attitudes towards an elderly person that endangers or impairs the elderly person's psychological health, such as acts of insult, scolding, isolation, causing fear to the elderly person for a long duration, intrusion into the elderly person's privacy and unnecessary restriction of the elderly person's freedom of access and movement.	Examples include: An elderly person being subject to constant cynical remarks, scolding, neglect, intimidation, nit-picking or loathing. An elderly person being subject to frequent isolation and not allowed to contact his / her family members, grandchildren and friends. An elderly person being forced to leave home or stay only in his/ her room during daytime and forbidden to use the facilities and common area of the house. Psychological abuse often co-exists with other types of abuse, and may also worsen gradually and turn into physical abuse. The following signs are shown with regard to an elderly person's emotional state and behaviour : extremely passive often showing extreme apprehension being afraid of the carer avoiding contacts with others depression tendency emotionally disturbed attempting suicide hysteria
3. Financial abuse	It is any act which involves depriving an elderly person of his/ her wealth, or not acting in an elderly person's interests, such as taking away an elderly person's possessions, money or transferring his/ her assets without consent.	An elderly person opens a joint account with another person who later withdraws money from it unilaterally. An elderly person suddenly transfers his/ her properties to another person, or purchases a property jointly with another person who later sells it unilaterally. An elderly person suddenly loses possessions or assets belonging to him / her. An elderly person has inadequate resources to cover daily basic necessities and daily living expenses even though he / she should be financially sufficient. An elderly person suddenly makes a will to leave all or most of his / her possessions to a non-related person. An appointee or agent entrusted to receive or keep in custody of the Comprehensive Social Security Assistance payments on behalf of an elderly person uses the money without the elderly person's consent. An abuser obtains an elderly person's money by forging his/ her signature, using the elderly person's seal without authority or tricking the elderly person into signing a blank withdrawal slip or cheque. An abuser decoys or forces an elderly person to hand over his / her money or property by deceiving, injuring and threatening the elderly person.
4. Neglect	It is severe or persistent lack of attention to an elderly person's basic needs (e.g. adequate food, clothing, shelter, medical treatment, nursing care, etc.) that endangers or impairs the elderly person's health and safety. Neglect also includes the failure of provision of medicine and aids according to medical advice, which causes physical harm to the elderly person. If a formal carer (e.g. Residential Care Home for the Elderly, Integrated Home Care Services Team, Hospital, etc.) fails to perform its caring responsibility and causes harm to an elderly person, the case may also be considered as neglect.	Elders may have the following conditions: serious loss of / extremely low weight, dehydration or malnutrition chronic bed sores lacking medication / medical care needed having dirty appearance frequently wandering around frequently or for prolonged period without being accompanied
5. Abandonment	It is the act of abandoning an elderly person without justifiable reasons committed by a carer or guardian, which endangers or impairs the elderly person physically or psychologically.	Elders may have the following conditions: wandering alone on streets, in parks or malls, etc. for a long period of time having dirty appearance for a long period of time no one paying visits or making arrangement for the elderly person's discharge after the elderly person's admission to hospital. For instance, the carers intentionally take the elderly persons with dementia to an unfamiliar place, making the elderly persons unable to return home by themselves. Or upon the elderly persons' admission to hospitals, family members refuse to provide or give wrong correspondence addresses / phone numbers, resist / avoid contact repeatedly, which makes it impossible for the hospitals to contact the carers or guardians to discuss the medical and welfare issues of the elderly persons.
6. Sexual abuse	It is the act of sexual assault on an elderly person such as exposure of sexual organ to an elderly person, indecent assault and rape, etc.	Physical indicators bruises on chest / genitalia unexplainable sexual diseases unexplainable urethritis unexplainable bleeding in external genitalia, vaginal or anal area, etc. Behavioural indicators being extremely frightened when seeing the suspected abuser excessive masturbation drastic change in sexual attitude / sexual behaviour Environmental indicators torn, stained or bloodied underclothing

* Remarks: The behaviours or signs listed above may not necessarily be evidence of elder abuse. However, once they appear, we should be alerted and pay more attention to the elderly person. Where necessary, assistance of relevant professionals (e.g. social workers, healthcare personnel and police officers, etc.) should be sought as soon as possible.

Risk Factors of Institutional Abuse of Elderly Persons

1. Factors related to the elderly victims - Elderly persons with poor physical health who require high level of care, e.g. physical disability, visual and hearing impairment, having dementia or behavioural problems such as physical and verbal aggression
2. Factors related to the abusers
   1. Characters and traits - Harsh and unreasonable, authoritative, in lack of empathy, poor conflict resolution skills, disrespectful to elderly persons (e.g. displace anger on them), past history of abusing elders
   2. Personal factors – Family problems / stress, e.g. marital problem, problems with caring of children and family members, financial stress
   3. Work environment - High work stress, even to the point of burn-out, disharmonious working relationship with the other staff and the elderly persons under their care, or even with past conflicts with them
3. Factors related to the organization
   1. Insufficient manpower and thus increased workload, leading to excessive stress to the staff
   2. Officer-in-charge has poor understanding of the frontline working condition with insufficient work supervision and monitoring of the frontline staff
   3. Insufficient staff training, resulting in deficient elderly caring knowledge and skills in the staff
   4. The institution does not pay enough attention to the issue of institutional elder abuse, leading to low awareness about elder abuse prevention

Prevention of Institutional Elder Abuse

1. Advice for the supervisory staff
   1. Arrange regular training for the staff - Arrange training for the staff especially for the newly joined so that they can learn the appropriate caring skills (e.g. how to handle elderly persons with emotional and behavioural problems) and stress management skills. Training can also increase their awareness towards elder abuse and help them to identify early signs of elder abuse
   2. Mutual communication with the staff - Monitor the working condition of the frontline staff regularly. Reinforce those who perform well. For those who under-perform, identify their difficulties and provide concrete advice with guidance. Maintain mutual communication and encourage the staff to put forth their suggestions. Provide channel for them to report suspected cases of elder abuse. On the work arrangement, assign reasonable workload and work schedule to the frontline staff lest they are subject to excessive work stress and negative mood for a long period of time which could in turn lead them to vent their distress to the elderly persons
   3. Arrange activities for the elderly persons to help them relax - Arrange suitable physical and social activities regularly for elderly persons in the institution. This can help soothe their mood and reduce their chance of displaying emotional and behavioural problems
2. Advice for the frontline staff
   1. To care for the elderly persons
      1. Be sensitive
         If elderly persons have difficulties in communication, staff are suggested to use simple questions or even assisted with graphics to get to know their health condition and needs. For the elderly persons who are introverted and quiet, frontline workers need to take initiative to show care and concern for them. To prevent neglect, staff should pay more attention to elderly persons' biological needs, provide care appropriately and safely (including providing sufficient fluid, food, medication, assistive aids e.g. walking stick, glasses, dentures etc., clean and safe environment). If elderly persons are bedridden, staff need to take steps to prevent bedsores (e.g. changing their posture regularly). If elderly persons feel unwell, one should report to the supervisor immediately for arrangement of medical consultations
      2. Be empathetic
         When elderly persons refuse to cooperate or are unable to follow instructions, try to observe if their health condition and cognitive abilities have changed. Adjust our expectations on them and nursing care needs for them accordingly. Be empathetic and receptive. Having the mindset of "being in others' shoes" in elderly care would prevent conflict from happening and reduce our work stress
      3. Be caring
         If elderly persons have behavioural problems, with the prime concern of protection of personal safety, staff should appease elderly persons' emotions first before solving other problems. Seek your supervisor and co-workers' assistance if needed. Do not scold the elderly persons loudly or react aggressively towards their violent behaviour. Meanwhile, avoid treating the elderly persons by punishment or threat
   2. To care for yourself
      1. Anger management - We should manage our angry emotion promptly to avoid escalation of anger. Otherwise, we may end up in venting our anger towards the elderly persons or even result in hurting them. If the condition is safe, calm down ourselves by leaving the scene, drink some water or find a quiet place to do relaxation exercises (e.g. mindful breathing, deep breathing and progressive muscle relaxation exercises)
      2. Stress management - Excessive work stress could increase the risk of elder abuse. Identify and manage your stress early. Learn about effective stress management and help-seeking methods
      3. Help seeking - Seek help from your supervisor and co-workers within the institution for support in a timely manner. If you are emotionally disturbed for a long time, please seek medical consultation promptly

Handling Institutional Abuse of Elderly Persons

1. Advice for frontline staff - Other than taking our responsibility to protect elderly persons, we should also look for signs of abuse, especially in those elderly persons who are physically or cognitively impaired. Report suspected case to officer-in-charge immediately so that both the elderly victim and the abuser could receive help promptly.
2. Advice for supervisory staff - If you find or suspect any incident of elder abuse in the institution, please refer to Chapter 9 'Procedures for Handling Institutional Abuse' in the Procedural Guidelines for Handling Abuse Cases by the Social Welfare Department for appropriate management.