Recently a conference was organised on elderly abuse. I was rather disturbed by the ethical input as the concept is certainly not merely a philosophical one and is very elusive. Certainly it is easy to speak about the responsibility of doctors to report such cases, but when it comes to family medicine, the problem is not so simple as I hope to show with the following cases from my own experiences – cases which I have been mentioning to consultant geriatricians in the teaching of ethics in the elderly population.

In the first case a patient visited my clinic and expressed concern at how her aunt was being treated. Her aunt, a spinster, had invited her nephew years before to live with her, when he got married. Of course years go by and children come along – in this case two boys – and the children grow old and demand their own room. What initially is pocket money to buy sweets starts becoming some sort of obligatory salary and instead of the family paying any rent, out of the generosity of this woman, the wife demanded some compensation for washing of the clothes and shopping. As the boys required a room of their own, this now elderly lady sleeps under the stairs.

The abuse escalated over the years. The boys would verbally and physically abuse the woman if she did not give them money. The mother would take the rest. The lady slowly became very depressed and her only outlet out of the house was a visit to this patient of mine who was now in front of me. She said that she never knew about the whole story as of course the woman was afraid to speak and to be thrown out of her own house. The solution initially was to arrange for a consultation with a consultant geriatrician. The story was confirmed and social services arranged for immediate transfer into an old people’s home for her safety. The tragedy of course was that the abusive family were in the end the people who gained the most. They now automatically had the house to themselves and it seemed that even legally there was nothing one can do. The lady would not sign any contract as she did not want to create scenes.

In a second case an elderly lady was abused by her single daughter who lived with her. She spoke to her sisters (the daughter’s aunts) who sided somewhat with the daughter, who used to speak like a martyr that she could not get married because of her mother. One day the elderly lady was admitted to hospital with bruises, which the daughter claimed were due to a fall. A long standing story of physical abuse transpired from what the mother related in hospital. The story was very traumatic to the mother as she tried even to play it down. Relatives however confirmed that the daughter had often said that she had to use violence. It was a very difficult and painful period for all and in the end, following considerable threats by the daughter of ‘malafama’, the woman was taken to a home. Again the old lady felt that she did not deserve this treatment – being kicked out of her home. Often she was on the verge of returning upon conviction and feigned repentance of the daughter.

In a third case a woman with five sons and a daughter presented herself with confusion and dementia. She lived with the daughter and was depressed because one of her sons, who was at loggerheads with the husband of the daughter, would not visit her in her daughter’s house. He would not put aside the feud for his mother and being the elderly and dominant brother demanded that the rest accept that the mother be put into a home so that all could see her whenever they wanted to. This was a nice family all in all but they could not resolve this issue until one day I had to admit the mother to hospital for chest pain. When she recovered no one would take responsibility and she was (abusively) left in hospital. A couple of weeks later the woman was transferred to a home where she died a month later.

All three cases have considerable psychological baggage. In the first case we see outright abuse which escalates over time. The people themselves are not bad people and in fact think they are doing a service to this old lady. The wife buys her food, cooks the diet she prefers, does her washing, and sees to her needs. The boys have got used to pocket some money and become violent by pushing and sneering if she does not give them what they request. But boys are young and correction by the mother is to no avail. They grew up in an environment in which no particular respect was given to this lady. What about the family doctor? What about him? He is never brought in unless really needed and in this case it is the family doctor and not her former doctor who is called. They were ironically trying to arrange to get her into a home. They succeeded without any effort. The wife was the first to go to the home and take back the television set when the woman died in the same home a few years later.

The morale of the story is that we should listen to relatives who complain and try to set up a meeting. Now this is not always easy as we do not know whether this niece was simply envious. I knew her for some time and knew her character well. But in family medicine you learn and continue to learn. Things are not always what they seem. It was very clear-cut however in this case and we could take the immediate necessary action. Malta being Malta, the family members were simply told that the woman had to be admitted to a home because of her age. No action was taken and no evidence was gathered.

The second case presents a very painful picture. Of course not all the details can be given. People taking care of elderly are not always competent to do so. They often have problems of their own. They find it difficult to run a social life unless they have the confidence to leave the ‘patient’ at home alone. Pressure by the patient often accumulates over years in that the person feels guilty even to go out. It starts with some verbal abuse and then some pushing and forceful shifting when cleaning the clothes; anger when they trip or soil their clothes. Then, if they do not eat what is prepared for them, perhaps some forceful feeding and even a hit here and there. Suddenly it escalates to pushing and hitting. The person feels guilty and buys gifts, whitewashes the bedroom and is all caring for a while – until the tension rises again. This cycle is well-documented in domestic violence. The downside is that it rarely can be detected, even by family doctors, unless the person speaks out. If there is dementia it becomes more difficult to prove.

The situation is usually detected by an element of suspicion. In this case recurrent falls were the excuse for the bruises but whenever these occur the doctor was never called in. It is often also the case that another member of the family speaks to his or her own doctor about the situation. A family conference often reveals a considerable amount of information. Of course the brothers and sisters of the women were all in sympathy for the daughter as their sister was described as always being somewhat of a fusspot. But when confronted with whether they wished their sister to continue to live in those conditions they finally gave in. All the evidence was there. It was merely explained to the daughter that over time she developed a severe amount of tension and she was venting out her frustrations on her mother. In this case even the gifts were related to periods when the daughter had expressed her attitude to her aunts.

Taking action is not easy. It is not easy to take an elderly person out of the home. And often the aggressor is simply suffering from a depression and is not getting any help. They feel let down that after years of taking care of parents or relatives, they are then seen as the aggressors. Perhaps leaving things ‘alone’ as we do in Malta helps. However it certainly does not help as a deterrent. We should heed people when they tell us that they cannot cope with the elderly they take care of any longer. Often taking care of elderly has its benefits monetarily which can be the cause of people not seeking help, as in this case. The paid-for electricity and water bills come in handy. The situation is complicated. But there are two things which can be readily done.

The first is to recognise family medicine as a speciality and train this specialist in the detection of any form of domestic violence and equip them with the tools of what to do and when to intervene. It is a pity that the attachment with practices in the current vocational trainee system is not enough to get sufficient exposure. It is also a pity that doctors are still being sent out into the community without vocational training, unless, that is, they want to work in health centres, where the EU directive only seems to be interpreted to apply. Family medicine is not a speciality just for the sake of being called a speciality. In many countries where vocational training is in place, the trainee doctor spends three years working in a practice. They learn from colleagues, have discussions and learn that the solution can be handled in the community. Often it is unfortunate that locally we have to wait until the patient is admitted to hospital for some reason.

The second is to continue investing in homes in the community. Ideally these homes should be in villages and give preference to the villagers so that they can be close to relatives and relatives close to them. The paradoxical problem is that we have put too many restraints and conditions to have homes. Recently relatives of mine inherited a large house and I had the idea of utilising the site as a home for the elderly. The limiting factor was the new regulations. At the time there was a different parliamentary secretary for the elderly with whom I could speak quite frankly. When she gave me the lists of conditions, including having not more than two people in a room (and soon it was to be one) and private toilets and special beds etc., etc., one could realise that things are laid down in good faith, but the reality is that there are many people living in homes – especially homes run by nuns, where these conditions are not met. And they work very well and people are happy. To set conditions is easy; you may not realise you are blocking progress.

This is happening across the board and is a sign of progress. A patient of mine who owns a restaurant and wants to have another floor upstairs has paid over a hundred thousand euros in permits and conditions and it was even imposed upon him that he should have a parking lot and a ramp for wheel chairs. Now if this was a new venture, perhaps it could have been justified. But all he wanted to do was create a pizzeria upstairs. Business is impeded in this way. It is the same with those who wish to offer a service for the elderly. It is true that profits are made, but the fees are already prohibitive as they are. People pay up to fifty euros a day in a private home. But if the investment is prohibitively high the results are that either people are not able to afford (except the rich – as it is today), or that investors are simply discouraged.

The solution is that if government wants conditions, perhaps it can help in some way. The alternative of having large contractors building large old-peoples’ homes is simply having other large SVPRs. Rather than considering large homes as the Zejtun or Bormla homes, we should consider the large houses which can be converted easily into small homes which can accommodate 20 or so residents in their own village. After all, we boast lateral thinking as a national pride.

Pierre Mallia is Associate Professor in Family Medicine, Patients’ Rights and Bioethics at the University of Malta; he is also Ethics Advisor to the Medical Council of Malta. He is also former president of the Malta College of Family Doctors.