EN Official Journal of the European Union C 44/109

Opinion of the European Economic and Social Committee on ‘Elder abuse’

(2008/C 44/24)

In a letter dated 16 May 2007, the vice-president of the European Commission, Ms Margot Wallström asked the European Economic and Social Committee under Article 262 of the Treaty establishing the European Community to draw up an opinion on Elder abuse.

The Section for Employment, Social Affairs and Citizenship, which was responsible for preparing the Committee's work on the subject, adopted its opinion on 2 October 2007. The rapporteur was Ms Heinisch.

At its 439th plenary session, held on 24 and 25 October 2007 (meeting of 24 October), the European Economic and Social Committee adopted the following opinion by 144 votes in favour, with three abstentions.

1. Conclusions and recommendations

1.1 Article 25 of the Charter of Fundamental Rights of the European Union (adopted in Nice on 7 December 2000) recognises and respects the rights of older people to lead a life of dignity and independence and to participate in social and cultural life. In Europe, the number of people aged 65 and over is increasing significantly. The challenge of the future will be to tackle this demographic change in an affirmative way, eschewing any sense of old age being a burden on society or posing a threat to the individual.

1.2 Part of this challenge includes tackling elder abuse — a much-neglected issue that still tends to be trivialised and pushed into the background. Particular risks are faced by older people who are dependent on care and/or are isolated within their own homes or resident in care facilities. The Committee would therefore urge the EU Council presidencies to address the issue of elder abuse, particularly within a care setting. The above comments are addressed to the EU Council presidencies, the European Commission and Member State governments.

1.3 The onus for preventing elder abuse lies mainly with the Member States. However, as this is a phenomenon prevalent in every Member State, the Committee feels that a pan-European strategy is needed. — Since elder abuse is a breach of human rights and a violation of the Charter of Fundamental Rights of the European Union, the Committee would ask the Commission to draw on existing treaty arrangements to put in place a comprehensive strategy to prevent abuse of this kind. — This pan-European strategy must be underpinned by an EU-wide study of elder abuse, particularly within a care setting. This report should seek to take stock of the current position, setting out prevalence rates and providing information on the various kinds of abuse involved, as well as causes and risk factors. The study should cover care provided both at home and within an institutional setting. — The study should seek to correlate the scale of risk facing older people — along with their legal position and the options open to them for assistance and support — with the provisions in place to tackle child abuse. — In the interests of protecting older people in the Member States, the study should also assess the stage reached in the implementation of the Charter of Fundamental Rights of the European Union. The above comments are addressed to the European Parliament and the European Commission; Directorate-General for Employment, Social Affairs and Equal Opportunities.

1.4 Elder abuse, particularly within a care setting, can only be effectively prevented by action at the appropriate national level. Thus, to combat abuse of this kind and as part of moves to forge a pan-European strategy, a national action plan must be drawn up — and the requisite funding made available — in each Member State. The national action plans should take particular account of the following points: — It is essential to break the taboo of elder abuse in a care setting by raising public awareness, for instance through information and education campaigns, of the plight both of those who are dependent on care and those who provide it. — General guidelines and appropriate legal bases should be established that are consistent with the Charter of Fundamental Rights of the European Union. — National reports are needed on the prevention of elder abuse in a care setting, whether provided at home or in a care facility. These reports should also include information as to whether (minimum) binding care standards are in place in the Member States, whether formal monitoring arrangements have been introduced and how successful such moves are in protecting older people cared for at home or within an institutional setting. — Steps must be taken to improve the information available to individuals and institutions directly involved in care, to boost their scope for action and to enhance cooperation. This also includes appropriate training and other initiatives for professional groups particularly concerned by the issue, for instance medical staff, carers and the police, and the establishment of rights for care facility staff to report abuse. — A broad-based, readily accessible and (also) confidential advisory service should be set up for all actual and potential stakeholders in order to fill any gaps in information about care issues at an early stage in the process. — Arrangements must be made to provide respite for family carers and advice and support for professional carers. — Networks should be established for cooperation, training and systematic exchanges of information among all players and institutions directly involved in care. The above comments are addressed to the Member States.

1.5 The Committee considers that a national and EU-wide exchange of good practice procedures and models is absolutely vital both to securing quality assurance and to promoting the development of care standards. The above comments are addressed to the Member States and the EUCPN.

2. Background

2.1 Age and the risk of abuse

2.1.1 Demographic projections indicate that the number of people in Europe aged 65 and over is set to increase significantly by 2050 (by 58 million, or 77 %). That increase will, in relative terms, be most marked among the very old (people aged 80 and over). This trend has an impact on daily life in many fields and poses particular challenges in virtually all policy areas.

2.1.2 Demographic developments are one (but not the only) factor making it all the more urgent to tackle the issue of elder abuse, as this is a much-neglected issue that still tends to be trivialised and pushed into the background. As a result, the empirical data available on the issue to date are inadequate and patchy.

2.1.3 Crime statistics indicate that men and women aged 60 and over face a substantially lower risk of violence than younger people and, in victim surveys, reports of having experienced violence are much less frequent among older than among younger people. Crime statistics and victim surveys are, however, ill-suited to registering and highlighting the specific threats of violence to which older people are exposed.

2.1.4 This is especially true for the risks of abuse run by older people in their close social circle from people they know and trust and on whom they might well even be dependent. Over the past few decades, scientists, policymakers and grassroots players have become alive to this area as one that harbours considerable levels of violence. The focus, however, has primarily been on children and women as victims (1), with little consideration given to the abuse of older people.

2.1.5 According to a definition established by the group Action on Elder Abuse that has been taken on board by the World Health Organisation (WHO) and has also gained currency in research circles and among policymakers, elder abuse is deemed to be a single or repeated act or lack of appropriate action which causes harm or distress to an older person (2).

2.1.6 Available data indicate that older people are frequently subject to sometimes extreme abuse, but that, apart from some exceptional cases, such abuse remains hidden from view (3). Findings of a representative survey conducted in 2006 in England, Scotland, Wales and Northern Ireland of over 2 000 people aged 66 and over living in private households (including sheltered housing) (4) show that, overall, 2,6 % of those questioned reported that they had experienced mistreatment involving a family member, friend, or care worker during the past year. That figures rises to 4 % if the prevalence of mistreatment is broadened to include incidents involving neighbours and acquaintances. The predominant type of mistreatment reported was neglect, followed by financial abuse, psychological and physical abuse and (least frequently) sexual abuse. Women are more likely to say that they have experienced mistreatment than men. These findings are comparable with those in other Western societies and are broadly consonant with the observed incidence of domestic violence. A 2004 study on the situation in Spain concluded that the abuse of older people is almost as prevalent as that of children.

2.2 Elder abuse in a care setting

2.2.1 The term ‘care’ has a broad meaning, ranging from help and support in the home to intensive care (in hospital).

2.2.2 Particular risks are faced by older people who are dependent on care and/or are isolated within their own homes or resident in care facilities. This exploratory opinion thus focuses on the circumstances faced by such older people, the specific risks to which they are exposed and the scope available for prevention and intervention.

2.2.3 Apart from the very oldest age group, it is still a minority of older people who require care. At the end of 2003, figures for Germany revealed care dependency of 1,6 % for 60-64 year-olds, 9,8 % for 75-79 year-olds, but 60,4 % for 90-94 year-olds (5). Projections indicate not only that the sheer number of older people is set to rise (see above), but also, and above all, that, of these older people, more will be infirm and dependent on care. Indeed, the number of those dependent on care is expected to rise by between 116 % and 136 %, while an ever sharper increase — of anything from 138 % to 160 % — is expected in the numbers of care home residents. The risks inherent in being dependent on support and care are set to rise, particularly among the very old (those aged 80 and over) (6).

2.2.4 The mistreatment of older people in a care setting is seen as a gerontological issue and includes not only the physical abuse of those dependent on care, but also any action or lack of action that has a serious negative impact on the life and wellbeing of older people (7). Types of abuse include (8): — direct physical violence (beating, shaking, pinching, the use of physical restraints, mechanical immobilisation, removal of physical aids, etc.); — indirect physical violence (unauthorised administration of medication, such as sedatives, etc.); — sexual abuse (disregard for an individual's boundaries of modesty, non-consensual sexual contacts, etc.); — emotional or mental violence (verbal aggression, disrespectful behaviour, ignoring the client, emotional coldness, social isolation, the threat of physical or other forms of violence or abuse, insulting or humiliating treatment, etc.); — financial or other kinds of material exploitation (unauthorised access to assets, sale of property without consent, attempts to cajole or force someone into gifting money, theft of money and valuables, extortion, targeting of older people by profiteers, etc.); — neglect (failure to provide requisite day-to-day support and sanitary and general care, especially lack of proper nutrition and hydration, the development of bedsores — decubitus ulcers — in bedridden patients as a result of poor care, etc.); — threats of abandonment or of being put in a home; — abuse of older people by enlisting them as test patients without their consent or against their will.

2.2.5 Older people may suffer abuse when being cared for both at home and in an institutional setting. There are no reliable data as to the prevalence of violence against care-dependent people in Europe. Little information is available on the phenomenon — hidden but generally deemed to be widespread — of neglect, abuse and violence against older people in a care setting.

2.2.5.1 Where care is provided at home, available studies estimate the percentage of cases where recipients experience violence at between 5 % and 25 % (9).

2.2.5.2 In a German study (10) on the abuse and neglect of older people living in residential or nursing homes, over 70 % of care staff questioned indicated that they themselves had resorted to violence or to other problematic behaviour, had failed to take action when action was needed, or had witnessed such conduct in other care staff (11).

2.3 Recognising abuse in a care setting

2.3.1 In practice, abuse is often difficult to spot. The main reasons for this include the tremendous sense of shame felt by the victims; dependence on the support, care and attention of the abuser and the resultant fear of reprisals or of making the situation worse; a practical inability to express the experience of having been abused because of illness, particularly organic brain deterioration; and uncertainty as to how to deal with situations where abuse is suspected.

2.4 Care provision at home

2.4.1 The vast majority of older people still live at home on a day-day basis. Care-dependent older people are looked after at home in many European countries. In Germany, for instance, this is true in some two thirds of cases, with only 7 % or so of those aged 65 and over living in care facilities. Family care is provided mainly by spouses, followed by daughters and daughters-in-law. The vast majority of such care provision is abuse-free, but abuse does still happen (see point 2.2.5.1 above).

2.4.2 Care in the home brings with it a number of strains, not least for the health, wellbeing and social contacts of those providing that care. Families sometimes have to sacrifice a great deal to look after older relatives. The problem is exacerbated by a lack of proper preparation for the care situation and poor support during the care period. Caring for older people who suffer from dementia presents a particular strain.

2.4.3 However, abuse perpetrated during care in the home is caused not only by the excessive strain on carers but also by a range of risk factors. These include the status of the relationship before the start of the care-dependency, substance addiction and mental imbalance of the carer, a sense of social isolation and inadequate social support, but also aggressive behaviour on the part of the care recipient (12).

2.5 Institutional care

2.5.1 Although, as things stand, only a small percentage of older people requiring care are looked after in an institutional setting, the number of people resident in nursing homes is set to increase significantly, particularly among the very old (see point 2.2.3 above). Even today, there is a trend away from care provided at home to care provided in facilities or by outpatient care services.

2.5.2 The vast majority of nursing homes are abuse-free. This is particularly true of homes that are officially recognised and monitored in the Member States and that scrupulously comply with the health provisions applicable in the country concerned.

2.5.3 Some nursing homes, however, do have a poor reputation. No systematic studies have been carried out into abuse in care facilities but checks made, for instance, by the medical services of health insurance companies, do indicate that nursing home abuse is not an isolated phenomenon (13).

2.5.3.1 Problems encountered include actual harm caused by poor care provision and shortcomings in areas such as nutrition and hydration. Other problems include the prescription of excessive doses of psychopharmaceutical drugs, major failings in the handling of medicines, and measures to restrict free movement.

2.5.4 Instead of being geared to the needs of their residents, poorly-run nursing homes are often marked by neglect and indifference Rigid timetables often run counter to the need for self-determination and independence among nursing home residents.

2.5.5 It is not only those dependent on care who suffer because care workers are short of time and overworked: such conditions also sow discontent among carers themselves. The staffing situation in nursing homes is exacerbated by the numbers of people exiting the profession early and the lack of properly qualified applicants. Virtually no attempts are being made to boost the attractiveness of jobs in the elder care sector.

2.6 EESC analysis and proposals

2.6.1 The abuse of older people is unacceptable wherever and to whatever extent it occurs and must not be further neglected. The Committee urges the EU Council presidencies, the European Commission and national governments to take steps to address the causes of abuse so that the older population is protected whether they remain at home or are in an institutional setting.

2.6.2 The EESC proposals therefore home in on the following areas:

2.6.2.1 Human rights

— Article 25 of the Charter of Fundamental Rights of the European Union (adopted at Nice on 7 December 2000) recognises and respects the rights of the elderly to lead a life of dignity and independence and to participate in social and cultural life.

— To achieve this, the Committee feels it is vital to take a new view of ageing. Greater attention should be paid to discrimination against older people, as this is often the cause of the mistreatment of older, care-dependent people. The challenge should, however, be to integrate older people into society and to consider their care as a shared task.

— The Committee stresses that older people have the right to live wherever they choose without the fear of harm and that discrimination against older people is unacceptable. The Charter of Fundamental Rights should apply for the protection of older people in whatever setting they live.

— The Committee stresses the importance of older people having the choice as to where they wish to live in relation to the amount of support they require. The Committee therefore urges national governments to develop a range of accommodation and support which is appropriate to individuals remaining at home, sheltered accommodation, residential care or long-term nursing care.

— Older people must have the ability to report incidents or concerns and be safeguarded in doing so. This equally applies to relatives and other carers who must have channels through which to take their concerns without fear of retribution for their relative or consequences for their own position or job security. There must be confidence that all reports will be sensitively and effectively resolved.

2.6.2.2 Improving data and the need for research

— The Committee proposes that further in-depth, EU-wide research be conducted to assess the extent of elder abuse in order to take into account the following: — to establish the prevalence rates of elder abuse in general and what constitutes the abuse experienced in a domestic and institutional setting; — the causes of abuse with a particular emphasis on the stresses experienced by family carers and the support they receive; — to what extent the Charter of Fundamental Rights is implemented in respect of protecting older people; — to what extent Member States have standards for the care of older people in place and how they are monitored and inspected.

2.6.2.3 Breaking the taboo and raising awareness

— The Committee urges national governments to take action to raise awareness of elder abuse through national media campaigns backed by practical support provided by statutory and voluntary agencies to break the taboo of elder abuse wherever it occurs.

— The Committee recognises that the media can play an influential role in changing public awareness and stresses that it should take a well-informed and constructive stance.

2.6.2.4 Information, education, training and prevention

— The Committee urges that national governments take steps to: — improve the information available to older people and their relatives on elder abuse; — ensure that professional carers are able to safely report incidents of elder abuse and are provided with sufficient advice and support; — ensure that there is sufficient training on the recognition of abuse and the mechanisms for tackling it for all those in the medical and care professions, including the police; — ensure that health and social services networks are enabled to provide emergency reception centres, support groups and independent, confidential telephone advisory services; — ensure that family carers are provided with sufficient information on the symptoms and progression of illness, such as dementia, to ensure that there is a strong understanding of the extent to which care could be required and to provide sufficient support, including training; — ensure that family carers have access to appropriate day care, respite care and medical support to alleviate the stress of potentially 24 hour care; — ensure that family members are supported to take time out of work to provide care with no detriment to their job prospects and that this should apply equally to men and women;

— ICT products and services (information and communication technologies) will make it possible for many older people to live in their preferred location for longer and thus maintain their independence and a high quality of life. ICT can help them in day-to-day matters and may also, where required, be used to monitor their health and activities, thus reducing the need for institutionalised care. ICT will make older people safer, and will also provide them with access to social, medical and emergency services and thus ensure that they can continue to live largely independent, autonomous and dignified lives.

2.6.2.5 Building up networks

— The Committee urges national governments to establish multi-agency networks to ensure co-operation, training and systematic exchanges of information (14).

2.6.2.6 Formal care monitoring

— The Committee calls upon Member States to establish high-level monitoring and inspection services to ensure high-quality services for older people based on clearly set- out and publicly available standards of care and that such bodies have the authority to take remedial action, the results of which should publicly be made available.

2.6.2.7 Increasing the detection of abuse

— The Committee stresses the importance of increasing the detection of elder abuse in a sensitive manner whether in a domestic or institutional setting, involving the appropriate agencies. There must be confidence that any abuse reported will be acted upon and change adopted. It should be recognised that the force of police or judicial action could be part of the process.

Brussels, 24 October 2007. The President of the European Economic and Social Committee Dimitris DIMITRIADIS

(1) On that point, see the EESC own-initiative opinion of 16.3.2006 on Domestic violence against women (OJ C 110, 9.5.2006) and the additional opinion of 14.12.2006 on Children as indirect victims of domestic violence (OJ C 325, 30.12.2006), rapporteur for both opinions: Ms Heinisch.

(2) Toronto Declaration on the global prevention of elder abuse: ‘Elder abuse is 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 can be of various forms: physical, psychological/emotional, sexual, financial or simply reflect intentional or unintentional neglect.’ (WHO 2002) (http://www.who.int/ageing/projects/elder_abuse/alc_toronto_declaration_en.pdf.); Action on Elder Abuse (www.elderabuse.org.uk).

(3) An international symposium held in Cologne in May 2006 under the patronage of European Commissioner for Employment, Social Affairs and Equal Opportunities, Mr Vladimír Špidla, reports a prevalence rate of between 5 % and 20 % for violence against older people in the various countries (Report on the symposium on Violence and grave neglect against the elders under domestic and institutional care conditions in the periodical forum kriminalprävention 4/2006 and 1/2007).

(4) UK Study of Abuse and Neglect of Older People (June 2007)

(www.natcen.ac.uk).

(5) German Federal Statistical Office (2005): 2003 care statistics — nationwide findings, Wiesbaden, Germany.

(6) North Rhine-Westphalia Crime Prevention Council, Germany (2006): Gefahren für alte Menschen in der Pflege (Risks for older people in a care setting).

(7) This definition is consistent with the Toronto Declaration on the global prevention of elder abuse (WHO 2002, see footnote 2).

(8) North Rhine-Westphalia Crime Prevention Council (see footnote 6), Toronto Declaration (see footnote 2) and the UK study (see footnote 4).

(9) Görgen, Thomas (2005a): Nahraumgewalt im Alter. Opferrisiken und Optionen für gewaltpräventives Handeln (Violence against older people from within their own close circle: victim risks and scope for preventive action) in the periodical forum kriminalprävention 3/2005, pp.13-16. Data on individual European countries may be found in Walentich/Wilms/Walter (2005): Gewalt gegen ältere Menschen in der häuslichen und institutionellen Pflege (Violence against older people in a domestic or institutional care setting) in the periodical Bewährungshilfe 2/2005, pp. 166-182.

(10) Görgen, Thomas (2005b): ‘As if I just didn't exist’ — Elder abuse and neglect in nursing homes. In: M. Cain & A. Wahidin (eds): Ageing, crime and society.

(11) Information on the prevalence of individual types of violence such as restraints on free movement or the misuse of psychopharmaceutical drugs may be found in Rolf Hirsch (2005): Aspekte zur Gewalt gegen alte Menschen in Deutschland (Aspects of violence against old people in Germany) in the periodical Bewährungshilfe 2/2005, pp. 149-165.

(12) Görgen 2005a (see footnote 9).

(13) In 2007, the medical service of the German health insurance bodies published a second report on standards in outpatient and residential care, indicating that 10 % of the care home residents surveyed had suffered impaired health — and had thus been exposed to inadequate care

(http://presseportal.de/pm/57869).

(14) Examples include the Bonn-based initiative to combat elder abuse (Bonner Initiative gegen Gewalt im Alter — Handeln statt Misshandeln e.V.) which in 2006 published the information leaflet Alte Menschen in Not — Wir können helfen (Old people in need — We can help). The International Network for the Prevention of Elder Abuse (www.inpea.net) also provides information on this and other initiatives.