Opinion of the European Economic and Social Committee on Elder abuse
Date: 2007-10-24
Institutions: European Economic and Social Committee
Subjects: care for the elderly, dependence of elderly persons, elderly person, fundamental rights, home care, public awareness campaign, violence

16.2.2008

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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 absten-
tions.

1. Conclusions and recommendations

Article 25 of the Charter of Fundamental Rights of the
1.1
European Union (adopted in Nice on 7 December 2000) recog-
nises 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 there-
fore 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 presiden-
cies, 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.

the Charter of Fundamental Rights of

— Since elder abuse is a breach of human rights and a violation
the European
of
Union, the Committee would ask the Commission to draw
on existing treaty arrangements to put in place a compre-
hensive strategy to prevent abuse of this kind.

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 Employ-
ment, 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 par-
ticular 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.

— This pan-European strategy must be underpinned by an EU-
wide study of elder abuse, particularly within a care setting.

— General guidelines and appropriate legal bases should be
established that are consistent with the Charter of Funda-
mental Rights of the European Union.

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— 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 arrange-
ments have been introduced and how successful such moves
are in protecting older people cared for at home or within
an institutional setting.

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.

— 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.

2.1.3
Crime statistics indicate that men and women aged 60
and over face a substantially lower risk of violence than younger
in victim surveys, reports of having experienced
people and,
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.

— A broad-based, readily accessible and (also) confidential advi-
sory 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 signifi-
cantly 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.

2.1.4
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 grass-
roots 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).

Available data indicate that older people are frequently
2.1.6
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

(2) Toronto Declaration on the global prevention of elder abuse:

(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.
‘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).

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(including sheltered housing) (4) show that, overall, 2,6 % of
those questioned reported that they had experienced mistreat-
ment 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 neigh-
bours 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
help and support in the home to intensive care (in hospital).

The term ‘care’ has a broad meaning, ranging from

action that has a serious negative impact on the life and well-
being 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, disre-
spectful 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.);

Particular risks are faced by older people who are
2.2.2
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.

— 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;

it

Apart

from the very oldest age group,

2.2.3
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

(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 — nation-

wide 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).

— 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 reli-
able data as to the prevalence of violence against care-dependent
people in Europe. Little information is available on the phenom-
enon — 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).

(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 indivi-
dual 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.

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In a German study (10) on the abuse and neglect of
2.2.5.2
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 daugh-
ters-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.

2.5 Institutional care

Although, as things stand, only a small percentage of
2.5.1
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.

The vast majority of nursing homes are abuse-free. This
2.5.2
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 reputa-
tion. 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 move-
ment.

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 resi-
dents.

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.

2.4.3
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).

(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).

2.6 EESC analysis and proposals

The abuse of older people is unacceptable wherever
2.6.1
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 institu-
tional setting.

(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 inade-
quate care
(http://presseportal.de/pm/57869).

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2.6.2
following areas:

The EESC proposals

therefore home

in on the

— the causes of abuse with a particular emphasis on the
stresses experienced by family carers and the support
they receive;

2.6.2.1 Human r ights

— 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 discrimi-
nation 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 protec-
tion 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 there-
fore urges national governments to develop a range of
accommodation and support which is appropriate to indivi-
duals remaining at home, sheltered accommodation, residen-
tial 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 retri-
bution for their relative or consequences for their own posi-
tion 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
experienced in a

the abuse

and what
constitutes
domestic and institutional setting;

— 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 moni-
tored 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 influ-
ential role in changing public awareness and stresses that it
should take a well-informed and constructive stance.

2.6.2.4 Infor mation, education,

training and preven-

tion

— 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 under-
standing of the extent to which care could be required
and to provide sufficient support, including training;

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— 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.

Brussels, 24 October 2007.

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 For mal care monitor ing

— 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 recog-
nised that the force of police or judicial action could be part
of the process.

The President

of the European Economic and Social Committee

Dimitris DIMITRIADIS

(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 Interna-
tional Network for the Prevention of Elder Abuse (www.inpea.net) also
provides information on this and other initiatives.