Cruelty to elderly people: do we care?

They say we should judge a society by how it treats its elders: is Britain tolerating mass abuse of pensioners in their own homes? Esther Oxford investigates

Most neighbours think 85-year-old Marianne Millard has done well for herself. Pinched and arthritic she may be, with hearing difficulties and Parkinson's disease, and yet she has that jolly bachelor friend Richard Butler to hold her hand and take care of her.

Home-helps who hang around the lone, rambling house long enough form a different opinion. They can see that Mrs Millard is attached to Mr Butler - a man 15 years her junior - but they also see her pupils dilate with fear when Mr Butler slides into the room. They are the ones who catch the tail-end of his frustrated shouts, then find Mrs Millard stripped of her night-dress, lying weeping and dishevelled in her bed. They are the ones who treat the unexplained bruises on her upper legs and arrange for the doctor to stop by when Mrs Millard succumbs to yet another vaginal infection.

Social workers, anxious about her well-being, have tried confronting Mr Butler. He says he feels angry sometimes, burdened down with responsibility, but denies maltreating Mrs Millard. He says he cares deeply about her. He even says his feelings for her are so strong that he won't ever let her live anywhere but his own home. Helpers look on, frustrated and afraid for her. There is little they can do.

In another part of the country live Arthur Clifford and his alcoholic son. Mr Clifford attends a local authority day centre - sometimes with a black eye. The day-care workers notice the bruises, but try to ignore them. Mr Clifford is incontinent. Clearing up faeces from the bathroom floor would get any son down.

The black eyes become more frequent. Carers take to bathing the frail old man. They find that the bruises are multiplying, over his arms, legs and torso. "How do you explain the bruises?" they ask the son. He can't. Soon after, the father and son move house. The pattern starts again.

Social workers have known for years that the family is not the safe haven idealised by the Victorians. Battered wives came to public attention in the 1970s. During the following decade, the alarm was raised about the sexual abuse of children, often by fathers. Now, many people are becoming concerned about the abuse of older people in the home, by younger family members, neighbours and "friends".

Ginny Jenkins, from Action on Elder Abuse - a campaigning organisation established in 1993 - is a vociferous advocate for the elderly. When she tells people to do something, she quotes figures from a national study published in the British Medical Journal in October 1992. "One in 20 people over the age of 65 are mistreated by family, friends or strangers within their own home," she says. "This translates as nearly 600,000 people."

The results of a survey published by Durham County Council in 1993 were equally disturbing. Daughters were found to be responsible for the maltreatment in 12 per cent of cases and sons for 7 per cent. Friends were found to be responsible for 9.5 per cent, neighbours 9.5 per cent, strangers and professional carers 7.1 per cent. Husbands were responsible for 4.8 per cent - wives the same.

Glen Garrod, who compiled the survey, says he was not surprised to find that daughters were found to be the most prolific abusers: "Some now have higher expectations in life and resent having to care for a parent. Others have been abused by the parental figure and are keen to get their own back."

The mistreatment of elderly people will get worse, Mr Garrod predicts, especially now that the family unit has broken down and second and third marriages become more common. "Often the second wife or third wife is left to look after the elderly person. The further removed the relative is, the less likely they are to be tolerant."

The range of abuse can run from verbal threats to arson, murder or rape. It can include physical violence, psychological or emotional abuse (including threats of abandonment or institutionalisation), material exploitation (the use of threats to enforce the signing or changing of wills) and neglect (wilfully withholding food or medication).

Psychological mistreatment accounts for nearly half the cases, according to the Durham research, with physical violence (including rape and sexual assault) and financial exploitation each accounting for 25 per cent of cases. Three-quarters of the victims had been mistreated for months or years. Only 4.7 per cent said that the incident was a one-off.

In some cases the issue is clear-cut: remove the offender, bring in home- help services, get advice from solicitors. But in most cases it is not. What can be done when the offender is the husband and the victim is an adoring wife, terrified of being left alone? What can be done about the 73-year-old man living in a council flat, whose home is pelted with mud and whose door-bell never stops ringing, when the culprits are neighbourhood kids?

The victims may also be hard to identify, says Dr Arup Banerjee, consultant physician in elderly medicine at Bolton General hospital and president elect of the British Geriatric Society. "They are likely to be people who are restless and mentally confused," he says. Yet many elderly people appear restless and mentally confused or display other so-called symptoms of abuse - depression, fearfulness, crying, refusal to talk - regardless of their situation.

There is no coherent legal framework designed to protect old people. Courts have to rely on legislation, some of which dates back to 1861, to take action if an elderly personis being mistreated.

This may change if recommendations from a recent Law Commission report on mental incapacity are adopted. Local authorities would be obliged to protect old people ear-marked "vulnerable" (not able to protect themselves from harm or exploitation). If they are seen to be in immediate danger, a temporary protection order may be obtained from a court, and the person put in a "safe-house" - that is, a hospital, nursing home or residential home.

Pressure groups and health workers are glad to see that the Government is taking the maltreatment of elderly people seriously, but feel that the proposed Bill is limited in scope. "The draft legislation does not provide permanent solutions. It does not necessarily make it any easier to prosecute people who are suspected of financially or sexually abusing an elderly person," says Bridget Penhale, vice-chairwoman of Action on Elder Abuse.

Nor does the Bill acknowledge how hard it is for old people to admit to themselves that they are being abused, let alone to an outsider from an official-looking organisation. "Today's old people come from a generation that has been taught not to wash their dirty laundry in public," says Roger Hitchings of Age Concern in Birmingham.

An average of four elderly people a month come in to the Birmingham office complaining of physical or sexual abuse. Another eight a month talk of financial exploitation. In both cases, these figures are just the tip of the iceberg, says Mr Hitchings. "I think we are seeing just one-tenth of what really exists."

Abuse by the spouse is the most difficult form of maltreatment to tackle, he says. Women of that generation "see rape as their husband's conjugal rights. It is unpleasant and distressing but they live with it. They even make excuses for it."

Sometimes abuse is suspected but workers are reluctant to intervene. The temptation is not to look, says Stephen Webster, consultant geriatrician at the Addenbrookes Hospital, Cambridge: "Abuse is difficult to prove and there is little help to offer anyway."

Dr Mark Lachs, from the Geriatrics Unit, Cornell University, New York, says the best way to find out if a patient has been abused is to ask. The American Medical Association takes this suggestion one step further: it recommends that all older adults be asked by their doctors about family violence - even if there are no symptoms.

Ms Jenkins can't see this happening in Britain. The medical profession here is apt to drag its heels, she says. Research by Action on Elder Abuse has shown that just one in five health authorities and one in four NHS trusts have any policy regarding handling of abused elderly people. "It is hard enough persuading doctors that there is a problem at all."

All names in the case-studies have been changed.