clinical focus
You said domestic violence perpetrated
by an older person requires clinicians
and families to consider a different
narrative to that which is predominant in
elder abuse. What is that narrative?
Most professionals would be aware of what
elder abuse is, so elder abuse would be
defined as acts of omission or commission
resulting in psychological, physical, financial
or sexual harm to an older person, and
that’s typically perpetrated by a person in
a position of trust. The paradigm of elder
abuse is that it’s essentially a stereotype
which views the older person as vulnerable
and frail, and these are characteristics which
are perceived to be intrinsic to older age.
Secondly, in elder abuse the older person
is generally prey to a younger aggressor.
For instance, we know that with half the
cases of elder abuse, it’s an adult son or
daughter who’s the perpetrator.
As I said earlier, the paradigm of elder
abuse is that we view the older person as
vulnerable and frail, so I think the difference
here in domestic violence is to recognise
that older people can be perpetrators as
well as victims of domestic violence. In fact,
there may be a long history of violence
between the couple. From that, you see it’s
a very different paradigm.
What more needs to be done to
recognise and manage this issue?
As with a lot of these issues, it’s education.
We’ve been surprised at the lack of
information out there, which is obviously
part of the reason we set up the seminar.
It’s something everyone in health
needs to have ownership of. GPs need to
be aware of it, emergency department
workers need to be aware of it, similarly
people who work in residential aged
care facilities. It needs a whole-of-health
response.
The other point I would make is that
it’s important to emphasise that it’s not
just the victim that we treat. A lot of
domestic violence services have been set
up to support victims, which is obviously
extremely important, but it appears that we
know far less about it.
Backtracking a bit, we know a lot about
the consequences of domestic violence in
victims, but one thing we tried to highlight
at the seminar was the importance of
determining what drives perpetrators to
engage in domestic violence, and also
the importance of treating perpetrators of
domestic violence.
There’s a lot of research on victims of
domestic violence. We know that they’re
at risk of things like anxiety, depression,
poor physical outcomes and chronic
pain, but there’s not so much research on
perpetrators of domestic violence.
In terms of domestic violence in older
people, there are two broad patterns.
We see domestic violence which is really
domestic violence grown old, meaning
that there’s been evidence of domestic
violence over many years. There are
studies suggesting that the average is
about 40 years. And while women can be
perpetrators, the majority of perpetrators
are men, and in these cases of domestic
violence grown old, the perpetrator
tends to be a man with a vulnerability or
personality disorder, typically someone
with controlling behaviour over the course
of the relationship, often with associated
alcohol abuse. They’re the kind of
pathology we’re looking for in those cases.
The second type of domestic violence
is so-called late onset domestic violence.
These are cases where there’s no past
history of domestic violence. They’re
really appearing for the first time in late
life, and the pattern we notice here is that
the perpetrator may experience dementia.
We know that memory impairment or
cognitive impairment in dementia is the tip
of the iceberg, and that dementia is often
complicated by psychiatric and behavioural
symptoms, such as aggression or agitation.
Obviously, if that aggression is directed
towards a partner, that by definition is
domestic violence.
That in fact is probably another reason
for the under-recognition as well, because
these cases tend to be considered cases
of dementia, meaning that we believe
that it’s the neuro-degeneration the
person experiences that contributes to
the domestic violence. But there may
also be something about the pre-existing
relationship between the couple that might
drive this behaviour, even if there has been
no previous domestic violence.
The other kind of pathology we see in
these late onset cases is psychosis, and
the commonest type of psychosis we
see is the perpetrator who has what we
call delusional jealousy – a belief that the
partner is having an extra-marital affair, and
it’s by definition being a delusion. It’s out of
keeping with reality and not in keeping with
the evidence against it. ■
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