Dementia and Abuse

People with dementia are often older and because of their illness vulnerable to abuse. Elder abuse arises in situations which are complex and difficult to handle so you need to know as much as possible about how to recognise it and what to do.

The World Health Organisation (WHO) (2016) defined elder abuse 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.” It is important to understand the law and practice in your own country, as it is different in Scotland, England, Wales and Northern Ireland.  In practice in Scotland the term “harm” is used more commonly than “abuse”.

1 in 10 experience abuse every month

“As a professional I have to consider if this relationship was always violent, or abusive, which makes the necessary response even more complex and sensitive.”

About one in ten people experience abuse every month, according to the WHO. The abuser is often a partner, child or other relative, a friend or neighbour, a paid or volunteer care worker, health or social care worker, or other professional.  Although the person with dementia may be abused, abuse can also happen to a vulnerable carer at the hands of the person with dementia. Recently I met with an older woman who cares for her husband. She was covered in bruises that she was trying to hide from me because she felt he did not know what he was doing and she was afraid of the outcome if she complained.

As a professional I have to consider if this relationship was always violent, or abusive, which makes the necessary response even more complex and sensitive.  It may also be that the conduct of the abuser causes the abused person to self-harm. The victim may be subject to deliberate neglect. Even if the person neglecting someone is unwell rather than malevolent, it is still abuse.

Some criminal acts perpetrated against older people are not classed as abuse.  A street thief may rob a person with dementia, but this is not abuse as defined by the WHO.  Street crimes perpetrated against vulnerable people call for a different community and policing response.  Abuse might involve a criminal act of theft, but it is only defined as abuse only if perpetrated by someone the victim trusts — someone you’d normally expect to trust, like a family member, a professional care worker, or a friend.

Abuse also occurs in a cultural context

In some cultures, older women have inferior status, and are in the control of a relative who cannot be challenged.  Exploring possible abuse within a family or religious setting is always complex. The key questions are about consent, and evidence of distress.  Knowing what distress caused by abuse looks like in a person with dementia is difficult, but someone who knows the person well may notice change over time.

Even so, elder abuse is more common in institutional than other settings.   It happens when care workers who are poorly trained, badly led, low paid and overworked, devise inappropriate practices to deal with complex problems. If the resident is being physically restrained, deprived of dignity and choice, overmedicated – these may all constitute abuse.   Even if fellow workers have serious concerns, they may be afraid or unsure how to raise them.  Being too busy, and fear of being a “troublemaker” have been described as barriers in the research. Misplaced loyalty or lack of confidence sometimes stand in the way of protecting vulnerable people.   

The abuse may be opportunistic, as when money from a wallet is taken or use of a credit card happens once by a family member who thinks the person with dementia won’t notice, and then denies it when asked.  It might be calculated, as when the abuser takes control of their finances and secretly spends the money on themselves, such as a person with Power of Attorney funding their own lifestyle from the bank account they should be managing.  In either case the perpetrator is exerting power wrongfully over the person with dementia.  

Risk factors exist for both the victim and the abuser.  If the victim has poor mental and or physical health and lives with someone who misuses substances including alcohol, there is a high-risk. Caregivers who are socially isolated, and have poor social support are at risk of becoming abusive.   There may have been a history of a poor relationship within the family, and the family member may be socially isolated. The carer may have mental or physical health problems. Although one has human sympathy for struggling carers, there are standards of behaviour that must be maintained for all vulnerable people.  Prevention is key, along with focussed response to any suspicions of wrong behaviour.

A person with dementia may be at considerable risk because they are not listened to, or they are regarded as an unreliable witness.  A civilised society is judged by how it cares for people and this problem is all too common.

World Health Organisation WHO (2022) http://www.who.int/mediacentre/factsheets/fs357/en/