探讨在基层医疗护理层面筛查老年人虐待 by Xintu

探讨在基层医疗护理层面筛查老年人虐待作者 Silvia Perel-Levin

基于同一作者的硕士论文在Philippa Sully指导下完成跨行业实践：社会，暴力与实践圣巴塞洛缪护理与妇产学院城市大学，伦敦，2005年7月

执行总结

1. 介绍

背景

一次对文献的批判性综述

文献回顾话题

文献检索的方法：列入和排除的标准

分析的方法

2. 老年人虐待定义什么是“老年”？

11 11 13

虐老的理论模型

老年人虐待和家庭暴力

老年人虐待与性别

人权方案

3. 筛查

定义

利与弊

筛查老年人虐待

既有的筛查虐老工具介绍

争论：要不要筛查？

基层医疗护理

Table of Contents

Executive Summary

1. Introduction

Background

A critical review of the literature

Literature review questions

Search strategy: inclusion and exclusion criteria

Methodology for analysis

2. Elder Abuse

Definitions

What is â&#x20AC;&#x153;oldâ&#x20AC;??

Theoretical models of elder abuse

Elder abuse and family violence

Elder abuse and gender

A human rights approach

3. Screening

Definitions

Benefit versus harm

Detecting elder abuse

Existing tools for detecting elder abuse

Should we screen? The debate

Primary health care

例行筛查还是例行询问？

病人的接受程度

筛查的障碍

信任

不同护理人员之间的交流

干预

培训

4. 结论以及对行动的启示

概括性结论

目前这篇综述的不足之处

对行动的启示

政策和实践

研究

培训

结论性评注

Routine screening or routine enquiry?

Acceptability by patients

Barriers to screening

Trust

Communication between different care professionals

Interventions

Training

4. Conclusions and implications for action

General conclusions

Limitations of the current review

Implications for action

Policy and practice

Research

Training

Concluding remarks

执行总结本文提出了一种文献的严格审查，并且讨论了需要做些什么提高初级卫生保健知识（PHC）工作人员在关于虐老方面的知识，和建议将筛查工作作为管理和预防老年人虐待的第一步。通过不同领域的文献报告，调查了目前对老年人虐待相关研究进展以及相关的其他类型的暴力，尤其是家庭暴力的研究进展，反应出老年人虐待的复杂性和解决老年人虐待的重重困难。本文还讨论了卫生保健人士在筛查和管理老年人虐待方面有形的和无形的障碍。虽然虐待长者是不是一个新现象，人口老龄化全球的速度将导致其绝对额增加除非我们采取行动来阻止它。虐待老人会给老人带来破坏性的后果，如，生活质量的下降，心理上的困扰，以及多种健康后果和死亡率的增加。广泛的年龄歧视已经渗透到生活的各个方面，使整个社会处于虐待和歧视老年人的背景下。虐待现象的性别不同被社会各个阶层在性别歧视方面所遮盖。性别歧视和年龄歧视，使老年妇女处于最脆弱的地步。这篇报告考虑了因为各国委员会缺少筛查家庭暴力的工具而导致加拿大、大不列颠以及北爱尔兰联合王国和美利坚和众国的卫生保健人员之间的辩论。在众多话题中，有关对虐待长者和筛查的定义的争论显示了，是医学模式为主导还是循证医学为主导的地位。本篇综述是对这种至高无上的地位的挑战，取而代之提出了一种人道主义模型。虐老是对人权的侵犯。初级卫生保健，通过提高病人对其照料者的信任，可以有效的识别、管理和预防老年人虐待。我们的观点是，通过实施例行检查的做法，自觉地与社区其他服务联合，虐老的现象，可以被预防或者至少可以妥善处理。跨学科的研究和实践，这种做法，不仅被诸多学者所接受，而且是基于所有有关各方之间的信任和有效沟通，将克服重重障碍，预防种种虐待老人现象的形式发生，将会走得更长更远。

Executive Summary This paper presents a critical review of the for domestic violence following the lack of literature, discusses what is needed in order to advance knowledge by Primary Health Care (PHC) workers about elder abuse and makes recommendations about detection as a first step for the management and prevention of elder abuse. Reflecting the complexities of elder abuse and the multiple barriers to tackle it, literature from various domains was used to explore current knowledge on elder abuse along with its relationship to other types of violence, especially domestic violence. The conscious and unconscious barriers that prevent health care professionals from detecting and managing abuse and what can be done to overcome these barriers are discussed. While elder abuse is not a new phenomenon, the speed of population ageing worldwide will lead to its increase in absolute terms unless action is taken to prevent it. Elder abuse has devastating consequences for older persons such as poor quality of life, psychological distress, multiple health problems and increased mortality. Widespread ageist attitudes permeate all aspects of life, acting as a societal background to abuse and discrimination against older persons. Gender aspects of elder abuse are obscured by sexist attitudes at all levels of society. Sexism and ageism together place older women as the most vulnerable to elder abuse. This review takes into consideration the debate among health care professionals about screening recommendations by screening committees in Canada, the United Kingdom of Great Britain and Northern Ireland and the United States of America. Controversies regarding definitions of elder abuse and screening reveal, among other issues, the supremacy of the medical model and evidencebased medicine. This review challenges such supremacy and proposes instead a humanistic model. Elder abuse is a violation of human rights. PHC has an important role in identifying, managing and preventing its occurrence by increasing the level of patientsâ&#x20AC;&#x2122; trust in their carers. This review argues that by implementing routine screening practice and by consciously working with other services in the community, elder abuse can be prevented or at least, managed properly. Interdisciplinary research and practice that acknowledge the person in context, and are based on trust and effective communication between all parties involved, will go a long way to overcoming barriers to tackling and preventing abuse against older persons in all its forms.

1. 介绍老年人口的增长是世界人口增长最快的部分。从全球范围来看，年龄在60岁或以上的人口，预计在未来的几十年内，将增长近三倍，暨从2006年的6.72亿万到2050年的19亿。而80岁及 80岁以上的年龄组，在面临着受虐风险的同时，其增长速度会更快。比如，在英国大不列颠及北爱尔兰，到2025年，80岁以上的老年人口的数量预计会增加近50%，而90岁以上的老年人数量将会翻一番。虽然，虐待长者并不是一个新的社会现象，但是，随着全世界范围内的人口老龄化的速度的增长，可能会导致这一现象的恶化。虐待老人会给受虐者带来破坏性的后果，比如，生活质量的降低，心理上的困扰和自身财产和安全保障受到威胁。同时也会增加患病率和老年人的病死率。虐待老人是一个世界性的问题，存在于发达国家和不发达国家社会的各个阶层。因此，他需要一个精心策划的跨学科的响应。从卫生和社会的角度来看，除非以初级卫生保健为基础、以法律和社会服务等为辅助，共同识别和处理这一问题，否则，虐老这一社会现象仍旧将不会被诊断，仍旧会被忽视。

背景虐老这一现象，像其他类型的人际暴力一样，仍然是隐藏的，是整个人类历史所忌讳的。虐老，是20世纪60年代和70年代继虐待儿童和家庭暴力公开被讨论之后，最初被称为“殴打老太”，后来以另一种家庭暴力的形式公开出现。虽然，虐待老人的现象最初是在1975年的英国科学期刊上刊登，但是其第一次大范围的、科学化和法制化的行动，还是发生在美国。在1990年，第一次，并且迄今为止，对虐老这一现象的广泛研究结果还是发表在英国。虐老，因不同的名称和定义而加重其本身的复杂性，导致外界对其的研究进展非常缓慢，很难捕捉到公众的视线和触及公共政策领域。因为它是多层次（生理，心理，法律，社会）的表现，所以需要不同类型的专业人士的参与。虐待长者这一现象的发生率的数据是基于发达国家开展的人口学研究中的少数部分。这些研究发现，4%至6%的老年人都受到了家中不同形式的虐待。老年人，在其他场所，诸如医院，疗养院和其他长期护理设施，也同样处于被虐的危险，但是至今还没有大规模的研究。

1. Introduction Older people are the fastest growing segment of the population world-wide (1, 2). Globally, the number of persons aged 60 years or over is expected to almost triple within the next few decades, from 672 million in 2005 to nearly 1.9 billion by 2050 (2). The very old group – aged 80 and over – who are at special risk of being abused, will increase even faster. For example, in the United Kingdom of Great Britain and Northern Ireland, by 2025, the number of people over the age of 80 years is expected to have increased by almost 50% and the number of people over 90 years is expected to have doubled (3). While elder abuse is not a new phenomenon, the speed of population ageing world-wide is likely to lead to an increase in its incidence and prevalence (4, 5). Elder abuse has devastating consequences for older persons such as poor quality of life, psychological distress, and loss of property and security. It is also associated with increased mortality and morbidity (6). Elder abuse is a problem that manifests itself in both rich and poor countries and at all levels of society (1). As such, it demands an orchestrated interdisciplinary response. From a health and social perspective, unless PHC services, legal and social services and other sectors of society are well equipped to identify and deal with the problem, elder abuse will continue to be underdiagnosed and overlooked.

Background Elder abuse, like other types of interpersonal violence, remained hidden and taboo throughout history. It was after child abuse and domestic violence began to be discussed publicly in the 60s and 70s that elder abuse, which initially was called “granny battering”, emerged as a form of family violence (7-10). While the abuse of older people was first described in British scientific journals in 1975 (11, 12), scientific and legal action was, and by large, first developed in the United States of America. In 1990, the first, and to date only, prevalence study on elder abuse was published in the United Kingdom (13). Elder abuse, a very complex issue with diverse definitions and names, has been very slow to capture the public eye and public policy. Since it is manifested at many levels (physical, psychological, legal, social), it requires the involvement of different types of professionals. Information on the prevalence of elder abuse is based on a small number of population-based studies that have been conducted in developed countries. These studies suggest that between 4% and 6% of older persons have experienced some form of abuse in the home. Older persons are also at risk of abuse in institutions such as hospitals, nursing homes and other long-term care facilities, but no large scale measuring studies are available (7, 10).

一个研究小组，受美国国家研究理事会委托，审查虐待长者的风险和发生率，强调了目前在研究虐待长者中的一些问题，如缺乏完善的理论框架，不明确和不一致的定义和措施，以及缺乏人群为基础的数据。在导致诸上众多问题的因素中，审查小组同样指出了研究经费的紧缺和研究人员的稀少，研究方法和伦理道德的不确定性，以及老年病学和家庭暴力等领域有不同的研究传统。参与一个多国研究的研究者，调查老年人和初级卫生保健人员对虐待长者这一问题的看法和建议，发现初级卫生保健人员应该协助老年人识别虐老现象。英国下议院卫生委员会2004年的报告估计，约有至少50万的老年人仍然受到虐待，并且指出，虐待老年人现象仍然是一个非常隐蔽的社会问题。卫生委员会指出，目前缺乏对护士和护理员在认识虐待老年人方面的培训，并且呼吁当下的护理课程应该包括识别和干预老年人和其他弱势群体的受虐问题。多年来，专业人士推荐通过标准化地协议和例行的筛查来开展针对家庭暴力的干预。然而，针对儿童受虐的设施已经在广泛开展，但是，对成年人的受虐的实践并没有广发开展，甚至没有得到合适的评估。 2003年，加拿大保健预防工作组表示，没有足够的证据开展针对妇女受到虐待的问题进行广泛普遍的筛查。2004年，英国国家审查委员会决定，基于Ramsay等人的研究，对成人受到家庭暴力的筛查不应列为常规的做法。同年，美国预防服务工作组指出，目前还没有足够的证据，开展对儿童、妇女和其他长者等家人和其亲密伴侣的行为进行筛查的益处和害处，因此不建议这样或者那样的方式开展。目前关于针对家庭暴力的筛查，以及虐老的问题，正在开展激烈的辩论。对现有的操作工具和存在的障碍和问题的评判性的评价，都可能会有助于在初级卫生保健水平的识别和干预策略的实施。在初级卫生保健方面，虐待长者可以首先被发现，或者忽视掉。初级卫生保健工作人员处于一个理想的岗位，在这一工作岗位上，可以识别、管理和预防虐老现象，同时，处于这一岗位的工作人员也可以对此问题视而不见。但是，他们大多都不去做诊断，因为首先，这一现象不是常规培训的内容，也不隶属于可以做出诊断的范围。初级卫生保健、法律以及社会服务，如果匹配不好，那么就很难去发现和处理这一社会问题。虽然在过去的几年中，对此问题的严重性已经得到了意识上的提高，但是，虐老这一现象，仍旧被忽视而未被诊断。

A panel to review the risk and prevalence of elder abuse, commissioned by the National Research Council in the United States (14), stressed many weaknesses in current research on elder abuse such as a lack of sound theoretical frameworks, unclear and inconsistent definitions and measures and a lack of population-based data. Among the many factors accounting for deficiencies, the panel pointed out little funding and few researchers, methodological and ethical uncertainties, and divergent research traditions in the fields of gerontology and family violence. Participants in a multi-country study on the views and perceptions of older persons and PHC workers on elder abuse, recommended that PHC workers are assisted in recognising signs of abuse among older persons (7). The 2004 report of the United Kingdom House of Commons Health Committee estimated that at least half a million older persons suffer abuse in the United Kingdom and acknowledged that elder abuse remains a hidden issue. The Health Committee showed concern at the lack of training on elder abuse for nurses and care workers and called for the identification of abuse of older persons and other vulnerable adults and for interventions to be included in the nursing curriculum (15). For many years, professional associations have recommended routine screening and the adoption of standardised protocols for the identification of and interventions on family violence (16â&#x20AC;&#x201C;19). However, while screening in paediatric settings is widely accepted, equivalent practice focusing on the adult population has not been adopted widely and has never been evaluated properly. The Canadian Task Force on Preventive Health Care stated in 2003 that there was insufficient evidence to recommend for or against routine universal screening for violence against women (20, 21). The United Kingdom National Screening Committee decided early in 2004, based on a report by Ramsay et al. (22, 23), that screening adults for domestic violence should not be introduced as a routine practice (24). In the same year, the United States Preventive Services Task Force (25, 26) stated that it could not find enough evidence to determine the balance between the benefit and harm of screening for family and intimate partner violence among children, women and older adults and therefore did not recommend one way or the other. There is currently a heated debate among health professionals around the issue of screening for family violence, including elder abuse. A review of existing tools and a critical appraisal of the different barriers and views may facilitate the introduction of detection and intervention strategies at the PHC level. Within the PHC context, elder abuse can be first identified â&#x20AC;&#x201C; or ignored altogether. PHC workers are in an ideal position to recognize, manage and help prevent elder abuse and neglect (5, 10, 27). However, most of them do not diagnose it, as it is not part of their formal training and does not appear in their list of diagnoses (10). PHC, legal and social services are ill-equipped to identify and deal with the problem. Although awareness of the problem has increased in the past few years, elder abuse continues to be underdiagnosed and overlooked.

一次对文献的批判性综述在此篇评判性的文献中，探索了初级卫生保健人员在对虐老认识和执行力度，以及强调了其对预防家庭暴力的关系。目前对筛检工具的讨论，在“利与弊”原则的指导下，探索了许多其中的困难。虐待长者的定义以及其筛检工具、支撑虐老的理论框架经过讨论后，还探索了如何与筛选相结合，以及跨学科工作的相关性。此外，还指出了虐待长者和性别虐待与初级卫生保健工作的能力建设之间的关系。本片讨论性的文章研究目标是： l

提高与筛选老年病人和虐老这一社会问题的意识；

l

围绕初级卫生保健人员对虐老这一问题的认识，确定哪些研究和培训仍然是需要的

l

对研究者以及政策制定者在发现、管理和预防老年人虐待方面提供政策建议。

文献回顾话题为了分析虐待长者这一现象的复杂性和探索不同的现象之间的关联，需要将该其分解成不同的部分和不同的小问题，予以回答。通过对文献的谨慎查阅，我们探索了下列的问题： l

什么是老年人虐待？

l

什么是筛查老年人虐待这一现象？

l

哪些是影响健康卫生专家发现和管理老年人虐待的主要障碍？如果扫除这些障碍的话，需要我们做些什么？

l

关于筛查老年人虐待和家庭暴力方面，有哪些是共同点和不同点？

l

如何从文献中收集证据来健全政策的发展和实践虐老筛查和管理？

文献检索的方法：列入和排除的标准鉴于长者虐待和家庭暴力的广泛影响，以及不同的研究领域和利益相关者的参与，我们针对文献研究中出现的问题做了搜索。最初的搜索是在电子数据库MEDLINE，CINAHL，AgeLine， PsycINFO和PubMed。此外，选定期刊、书籍，以及政府和政府之间的组织、学术和民间社会组织的网站，进行了额外的手工检索。最后，通过之前选定的出版物列出的参考文献、专家和教授的个人推荐以及通过谷歌搜索一般的网站，我们得到了许多值得参考的文献资料。

A critical review of the literature In this critical review, current knowledge as well as practice on elder abuse recognition by PHC workers are explored with an emphasis on its relationship to domestic violence. Current debates over screening tools looking at the principle of “benefit versus harm” invariably leads to an exploration of the many barriers to screening. Definitions of elder abuse and screening and theoretical frameworks that underpin work on elder abuse are discussed, and how these relate to the screening debate and the relevance of interdisciplinary work are explored. Furthermore, the relationship between elder abuse and gender and issues related to the capacity building of PHC workers are presented. The aims of this discussion paper are: l l

l

to raise awareness about the issues and debates around screening older patients for elder abuse; to identify what research and training are needed in order to advance knowledge among PHC workers about elder abuse; to make recommendations to researchers, practitioners and policy-makers for the detection, management and prevention of elder abuse towards policy development.

Literature review questions A breakdown into various components and questions is required in order to analyse the complexities involved in elder abuse and to explore how the different issues interrelate. The following questions are explored through a critical exposition of the literature. l l l

l

What is elder abuse? What is screening? What are the main barriers among health care professionals to detect and manage elder abuse and what can be done to overcome them? What are the commonalities and differences with regard to screening for elder abuse and domestic violence? How can the evidence gathered from the literature inform the development of sound policy and practice for the detection and management of elder abuse?

Search strategy: inclusion and exclusion criteria Given the wide implications of elder abuse and domestic violence, the different fields of study and stakeholders involved, several searches were performed as issues emerged from the literature. The initial search was performed in the electronic databases Medline, CINAHL, AgeLine, PsycINFO and PubMed. Additional handsearches of selected journals, books and web sites of governmental, intergovernmental, academic and civil society organisations were conducted. Finally, many references were identified through reference lists from previously selected publications, personal recommendations by colleagues or teachers and general internet searches through Google.

检索的关键词是：“老年人虐待”、“老年人不合理对待”、“虐待老年人”、“对老年人的暴力”、“家庭暴力筛查”、“妇女受暴力”、“老年妇女”、“家庭暴力与老年妇女”、“筛查工具”、“老年人虐待筛查工具”和“老年人的权力”。此外，用到了以下复合检索词：“老年人虐待+筛查”、“老年人不合理对待+筛查”。检索的年份限制在1995年至2005年。但是，由于缺乏虐待长者的重要研究，在1995年之前的重要的出版物也包括在内。最后检索出来的所有文献，主要是来自加拿大、英国和美国的研究（定性和定量）、研究评论、科学和专业期刊的社论、以及评论文章、政策报告和以英文出版的书籍。澳大利亚和南非的一些相关研究也包括在内。为了反映支撑本文的生态理论，如果研究的文章是与家庭虐老背景相关的、与老年人虐待筛查工具相关的、以及检查老年人虐待和家庭暴力的障碍相关、在付出时间方面的重要尝试（包括专业领域内部的尝试）等，本文都灵活的将其纳入目标研究范围。由于大部分，如果不是全部的的文献和争论在筛查障碍方面都集中在家庭暴力这一层面，那么为了分析虐老的影响而对该领域做研究，就显得非常重要。虽然在养老机构，诸如护理院、长期照料机构、疗养院和医院等，这里的虐老现象比较普遍，但是这些并不能列入本文的研究范围。但这个并不意味着他不重要。相反，他需要更加具体和详细的关注。我们现在将关注的焦点聚集到家庭和初级卫生保健，为了反映这一现实——暨虽然在媒体不断的报道养老机构内对老年人的虐待丑闻，但是绝大多数的老人是独立的，是生活在社区中的，但是仍然会成为受虐待的对象，而且是在自己的家中。只有当其涉及到筛查的程序和态度的时候，在相关的紧急部门的研究才会被实践。对儿童虐待的相关研究被排除在外，除非当其是与虐待老人做出对比研究时才被纳入目标范围。这一原则同样适用于对妊娠妇女和青少年的虐待研究。然而，对产前保健的研究被排除在外，对医护人员在对妇女在妇产科和产前设置的其他科室的筛查时的看法和态度的研究被列入研究范围。因为过程是相似的，同样因为亲密伴侣和性虐待的研究和筛查也是发生在这些科室里面。更重要的是，他反映了一个事实，暨老年妇女也可能是性虐待的受害者，很可能是在其单单地去妇科诊断室时，会发生这一现象，在任何年龄阶段的妇女都可能发生。

分析的方法我们需要对内容进行分析。由于资源的多样化，内容分析的主要目的是，找出该研究问题和目标相关的、当下的重要研究主题。通过阅读这些文献，我们发现并且评估了新的研究主题。由于缺乏除了美国以外对老年人虐待的研究，从文献阅读中发现的研究主题，看起来已经经过批判性的讨论了，因为其解释了缺乏对老年人虐待的研究，但是仍然在努力的寻找“大画面”。

The key words used were: “elder abuse”, “elder mistreatment”, “abuse of the elderly”, “violence against the elderly”, “domestic violence screening”, “violence against women”, “ageing women”, “domestic violence and older women”, “screening tools”, “elder abuse detection tools” and “rights of older persons”. Also, the following combinations of key words were used: “elder abuse + screening”, “elder mistreatment + screening”. The search was limited to the years 1995–2005. However, due to the paucity of primary research on elder abuse, a number of significant publications before 1995 were also included. The literature selected for the analysis was drawn from primary research studies (both qualitative and quantitative), study reviews, scientific and professional journal editorial and opinion articles, policy reports and specialized books published in English, mainly from Canada, the United Kingdom and the United States. Some studies from Australia and South Africa were also included. Reflecting the ecological theory underpinning this paper, flexibility was applied regarding the fields of the studies to be included, and their methodologies, as long as they were relevant to the issues of elder abuse in domestic settings, the right for health of older persons, screening tools for elder abuse, barriers to detection of elder abuse and domestic violence and significant contributions to practice, including interprofessional practice. As most, if not all, literature and debate on screening barriers concentrate on domestic violence it was crucial to include studies from that field in order to analyse the implications for elder abuse. Although elder abuse in institutional settings such as nursing homes, long-term care institutions, hospices and hospitals is believed to be highly prevalent, it has not been included in this review. This in no way implies that it is less important. On the contrary, it requires specific and detailed attention. The focus on domestic settings and PHC reflects the fact that despite scandalous stories depicted often in the media about institutions, the majority of older persons are independent, are living in the community and can be victims of elder abuse anywhere, principally in their own homes. Studies conducted in emergency departments were included only if they related to screening procedures and attitudes. Literature on child abuse was excluded, except when being compared to elder abuse. The same applies to literature on abuse of pregnant women and adolescents. However, while studies on antenatal care were excluded, studies of perceptions and attitudes of health care professionals and women on screening at gynaecological and antenatal settings were included, because the processes are similar and because the majority of studies on screening for intimate partner and sexual abuse are conducted in those settings. More importantly, it reflects the fact that older women may also be victims of sexual abuse and may independently also see gynaecologists who in fact can fulfil the function of first point of contact like emergency departments, for women of any age.

Methodology for analysis A content analysis was performed. Because of the variety of types of source, the main objective of the content analysis was to identify major and recurrent themes related to the aims and questions of the study. Through the reading, new themes were identified and evaluated. Because of the paucity of primary research on elder abuse outside the United States, such themes that emerged from the reading seemed appropriate to be discussed critically as they explain the lack of focus on elder abuse in primary research while still looking at the “big picture”. 10

2. 老年人虐待定义关于“虐待长者”这一说法有很多的争议。其他经常使用的术语还包括“不合理对待长者”和“老人的照顾不够”等。因此，关于如何界定虐待长者并未达成共识。然而，正是因为缺乏对这一名词的商定的定义，在过去的25年中，基于不同的理论干预也不同。英国卫生部的文件“No Secrets（没有秘密）”将老年人虐待定义为“侵犯个人的人权和公民的权利”。这一文件并不是单单地针对老年人，他面向所有脆弱的成年人。英国的“针对虐老行动”对“虐老”做出了定义，随后，国际预防老年人虐待的国际网络和世界卫生组织均使用了这一概念： “在本应充满信任的关系中，发生的一次或者多次致使老年人受到伤害或者处境困难的行为，或以不采取适当行动的方式致使老年人受到伤害或处境困难的行为”。需要注意的是，在这个定义中，排除了对老年人的随机暴力或犯罪行为。对老年人的虐待，与犯罪行为相重叠，但是虐待老年人并不是犯罪行为的代名词。受虐和施虐者之间的信任关系——如合作伙伴，孩子，公婆，孙子女，护士，社会工作者和家庭帮助——是问题的核心。这种关系可以是正式的或者非正式的，自愿的或者法律、社会所约束的。虐待老人可以看做是对信任关系的背叛。虽然没有共识的定义，但是目前大部分文献，将虐老这一问题划分为五个类型或类别：生理的，心理/情绪的，经济上的，性关系的，以及忽视。如表1所示。一些文献还包括了“权利的冲突”，这一类别，剥夺了通过法律或者律法而赋予老年人的权利。每种虐老类型可以单独出现，或者以多种形式出现，并且是在特定的范围内出现，比如，在老年人生活的家中，日间护理中心，医院和疗养院等。英国和美国的健康卫生领域和社会护理领域的专家以及对虐老做了定义和分类的描述，但是，对虐老的定义仍旧需要特定的文化背景。例如，在一些传统的社会中，年长的寡妇会受到一些残酷的虐待，比如，被遗弃，扣押财产，受到性暴力，强迫结婚，受到巫术的指控，以及被从家里赶出去。这些暴力行为和习俗被深深地嵌入特定的社会结构中，虐待老人和维护人权的范畴就需要拓展。

2. Elder Abuse Definitions There is controversy around the term “elder abuse”. Other terms often used include “elder mistreatment” and “inadequate care of the elderly”. Consequently, there is no consensus as to how to define elder abuse. Lack of agreed definitions reflects the different theories on which elder abuse definitions and interventions have been based over the past 25 years (4, 28). The United Kingdom’s Department of Health document No secrets (29) defines abuse as “a violation of an individual’s human and civil rights by any other person or persons”. No secrets does not relate specifically to elder abuse but concerns all vulnerable adults. The United Kingdom’s Action on Elder Abuse developed a definition subsequently adopted by International Network for the Prevention of Elder Abuse and used by the World Health Organization (WHO) (7, 10, 30): “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 is important to note that elder abuse in this definition excludes random acts of violence or criminal behaviour against older people. The harm of elder abuse overlaps with, but is not necessarily synonymous with, criminal acts (31). A trusting relationship between the abused and the abuser – such as partners, children, in-laws, grandchildren, nurses, social workers and home helps – is at the heart of the issue. Such a relationship may be formal or informal, undertaken voluntarily or imposed by a legal or social custom. Elder abuse is seen as a betrayal of trust (14). Although there is no consensus on a definition, most literature so far attributes to elder abuse five types or categories: physical, psychological/ emotional, financial, sexual, and neglect (7, 8, 10, 32– 35), as shown in Table 1. Some literature also includes as a category Violation of rights, denying an older person rights conferred on her/him by law or legal process (34). Each type of abuse may occur singly or in combination, and in a range of settings, such as people’s own homes, where the vast majority of older people live, day centres, hospitals and nursing homes (29, 31). The definitions and categories described have been developed by health or social care professionals in the United Kingdom and United States. But definitions require a cultural context. For example, in some traditional societies, older widows can be subject to cruel practices such as abandonment, sequestration of property, sexual violence, forced marriages, accusations of witchcraft and ejection from their homes. These acts of violence, customs embedded in the social structure, need to be considered in the broad context of elder abuse and a human- rights approach (7).

此外，在考虑对老年人虐待的定义、识别和干预时，考虑老年人自身的感受就非常重要。在世界卫生组织和国际防止虐待长者网络的研究中，老年人虐待分三大类： l

忽视，包括隔离，被遗弃和社会排斥;

l

违反人权，法律和医疗的权利;

l

对选择权，决定权，社会地位，经济能力和受到尊重的剥夺。

什么是“老年”？在世界不同的地区，年龄的划分不尽相同。在北美和欧洲，“老年”的年龄界定一般是65岁。但是，退休的年龄界定在这些地区也不同。在某些国家，退休年龄是成为祖父母，自身肢体功能弱化，或者依赖程度加强的标识，而并不是单单地指一个人的年龄。联合国对“老年”的年龄界定为 60岁，随着人们寿命的增加，婴儿出生率的下降，高龄老人（指人的年龄在80岁或以上）成为世界人口增长最快的部分，并预计从2005年的8600万增加到2050年的3,9400万。他们往往变得更加脆弱或者体弱，一系列的健康问题，比如中风，痴呆等，会随着年龄的增长，而越来越普遍。此外，在青年人被赋予希望和荣耀的社会文化中，老年人在社会中的角色就变得越来越不重要，甚至会成为弱势群体而被社会排斥。

虐老的类别

特征

身体虐待

肢体上施加痛苦或者损伤

心理/情感虐待

使遭受精神上的极大痛苦

财产/物质虐待

性虐待

忽视

举例击打，拳击，踢打，强迫喂食，限制，用物体打击等。言语挑衅或威胁，威胁送到寄居机构，使社会隔离，侮辱的话语

非法或者不恰当地利用和/或使用

窃取支票或现金，向老人施加压力以

基金或者资源

夺取资产，比如强制资产转移

任何非双方同意情况下与老人发生接触

挑逗性的对话，强迫发生性活动，触摸、爱抚一位不同意的有行为能力的老人或者一位无行为能力的老人

指定的看护者有意或无意地拒绝或

未能提供充足的食物、衣物、住所、

者未能满足老人的生活需要

医疗护理、卫生保健以及社会激励

表1：虐老的类别

In addition, older people’s perceptions are crucial in defining abuse, its identification and interventions. In the study by WHO/ International Network for the Prevention of Elder Abuse (7), older persons classify abuse under three broad categories: l l l

neglect, including isolation, abandonment and social exclusion; violation of human, legal and medical rights; deprivation of choices, decision, status, finances and respect.

What is “old”? Different age cut-offs are used in different parts of the world to define an older person. In North America and Europe, generally the cut- off age is 65 years. However, retirement ages vary in these regions too. In some societies, it is a function of becoming a grandparent, or the degree of disability or dependence and not the chronological age that makes a person old. The United Nations standard to describe older people is 60 years (1). As people live longer and fewer babies are born, the oldestold (people aged 80 years or over) are the fastest-growing segment of the world population and are expected to increase in number worldwide from 86 million in 2005 to 394 million in 2050 (2). They often become more vulnerable and/ or frail, as a range of health problems such as stroke and dementia become more prevalent at very old ages (3). Furthermore, in societies where youth is glamorized and glorified, older people become vulnerable to social exclusion.

Type of abuse

Characteristics

Examples

Physical abuse

The infliction of pain or injury

Slapping, hitting, kicking, force-feeding, restraint, striking with objects

The infliction of mental anguish

Verbal aggression or threat, threats of institutionalization, social isolation, humiliating statement

Psychological / emotional abuse

Theft of cheques or money, coercion to The illegal or improper Financial / material deprive the older person of his or her exploitation and/or use of funds or abuse assets, such as forcible transfer of resources property Sexual abuse

Non-consensual contact of any kind with an older person

Suggestive talk, forced sexual activity, touching fondling with a non-consenting competent or incompetent person

Neglect

International or unintentional refusal or failure of designated caregiver to meet needs required for older person’s well-being

Failure to provide adequate food, clothing, shelter, medical care,hygiene or social stimulation

Table 1: Types of elder abuse 14

虐老的理论模型研究者们试图解释老年人虐待的原因，从心理学、社会学和女权主义以及儿童虐待和家庭暴力的角度制定了几个理论模型： l

情景理论声称：照料负担过重，以及照料者的压力很大，很可能使老年人处于一个受虐的环境；

l

交换理论：解决的是受虐人和行为人之间的互惠性和依赖性问题。它表明虐待可能会发生在家庭生活中的战术和反应框架内；

l

个体内部动力（精神病理学）理论解决的是一个精神或情绪困扰的施虐者和虐待之间的关系。

l

世代相传或社会学习理论认为，一个成年人的行为与其儿时的习得的或者受到的行为相关，因此，当其成长为成年人的时候，就会自然而然地表现这些行为。

l

女权主义的理论基础是家庭暴力的模式，突出了内部权力关系的不平衡和男性使用暴力的方式来展示自身的权利。

l

政治经济理论驳斥了个人主义的理论，并声称社会内部的结构性力量与老年人的边缘化，为冲突和暴力创造了条件。现在已经非常明显，如果研究没有能够验证这些理论，那么就没有一个模式或理论研究可以解

释像虐待老人这样一个复杂的社会问题。为了克服单一模式的不足之处，以应对与虐待长者相关因素的多重性和复杂性，研究者们转向儿童虐待、青少年暴力和亲密伴侣暴力的生态模式，生态模式探索的是个人和情境因素之间的相互作用。他认为暴力的发生是由于人的个性特征（比如，生理因素、个人历史），人际关系，人们居住或工作的社区特征，以及诸如政策和社会规范的社会因素。生态模式将虐老现象与更广泛的社会问题联系起来。关注照料者压力的某一理论反应了这一事实，即对边缘脆弱老人的研究已经定义了老年人虐待这一概念。“性别”往往使问题变得模糊不清。对“照顾”这一话题的关注，使得“脆弱”往往关注于年龄，而不是家庭暴力或者更广泛范围内的性别歧视或者年龄歧视——对老年人的歧视和轻蔑。McCreadie 声称，必须用严格的语言澄清“护理”与“脆弱性”，“看护者”不能成为施虐者的婉称，也不能将“护理”和共同居住混淆。至于“脆弱”，McCreadie提醒我们，脆弱的人不一定是有受虐风险的，而那些处于受虐风险中的老人，不一定是脆弱老人。

Theoretical models of elder abuse Several broad theoretical models have been drawn from psychology, sociology, feminism and the fields of child abuse and domestic violence in attempts by researchers to explain the causes of elder abuse (28, 32, 35-38): l

l

Situational theory claims that an overburdened and stressed caregiver creates an environment for abuse. Exchange theory addresses reciprocity and dependence between the abused and the perpetrator. It suggests that abuse can occur within a framework of tactics and responses in family life. Intra-individual dynamics (psychopathology) theory claims a correlation between a mentally or emotionally disturbed abuser and abuse. Intergenerational transmission or social learning theory states that an adult’s behaviour relates to learned behaviour as a child, thus reverting to the same pattern in adulthood. Feminist theory is based on domestic violence models, highlighting the imbalance of power within relationships and how men use violence as a way to demonstrate power. Political economic theories have criticised the emphasis on individualistic theories, claiming that structural forces and the marginalisation of elders within society have created conditions that lead to conflict and violence.

It has become apparent that no single model or theory can explain such a complex issue as elder abuse as research has never been able to validate them (14, 31, 32). In response to the inadequacy of any single model and in order to accommodate the multiplicity and complexity of factors associated with elder abuse, researchers have turned to the ecological model (32, 39, 40) in line with child abuse, youth violence and intimate partner violence (41). The ecological model explores the interactions between the individual and contextual factors. It considers violence as the result of the complex interplay between the person’s individual characteristics (i.e. biology, personal history), close interpersonal relationships, characteristics of the community in which the person lives or works and societal factors such as policies and social norms. The ecological model allows elder abuse to be linked to broader social issues. Single theories that focus on caregiver stress reflect the fact that elder abuse has been defined and conceptualized mostly by professionals who deal with frail and vulnerable populations (28, 42). Gender issues often become obscured. The focus on the “caring” fixes the attention on vulnerability related to age rather than on the context of family violence or the wider contexts of sexism and ageism – the discrimination and stigmatization of older people. McCreadie (31) claims that rigour is needed in the language in order to clarify what is understood by “care” and “vulnerability”, that “carer” should not be used as an euphemism for abuser and that we should not confuse “caring” with co-residence. As for vulnerability, McCreadie (31) reminds us that people who are vulnerable are not necessarily at risk and that those at risk are not necessarily vulnerable.

虐待老年人的理论和研究需要关注社会中的年龄歧视、边缘化和性别歧视以及这些社会现象对虐待的影响。老年人虐待的研究理论中，有很长的一段时间，忽视了老年人自身对这一问题的看法和意见。越来越多的研究提供老人参与研究设计和行动的机会，或者收集老人自身对健康和服务的需求方面的看法，以及对少数民族群体中的老人的需求的看法和相应的干预策略。然而，这类研究的进展是缓慢的、零散的和小规模的，需要急迫和长期的努力来纠正这一情形，以便于对这一领域的实践产生明显的影响。跨专业理论的研究，需要考虑到生态模型理论不同层次之间的相互作用，以便于了解虐待长者问题的复杂性和采取相应的行动。

老年人虐待和家庭暴力伴随着虐老这一概念的定义、术语和原因的差异性存在的，还有一些关于虐待长者应该属于哪个领域的研究的争论，比如，虐老真的可以作为一个单独的实体来对待吗？或者他是不是像儿童虐待或者亲密伴侣虐待一样，属于家庭暴力的一个分支？无论是在研究人员的态度方面还是公共政策和服务方面，儿童虐待和亲密伴侣虐待的相似性和差异性都是显而易见的。虐待老人与其他类型的家庭暴力类似但是仍旧有不同点，现在，还没有足够的证据表明，将其视为一个独立的研究领域是合适的。但是，这个并不意味着，对虐老的研究可以独立出来展开。年龄本身并不定义虐老。比如，一个妇女在遭受亲密伴侣的暴力，但是不能因为她的年龄超过了65 岁，而构成虐待老人的案例。老年妇女事实上可能会一生都在经历性伴侣的虐待。但是正如Dyer, Connolly 和McFeeley所指出的，儿童虐待和性伴侣虐待的对象大多是健康的，并不会因为遭受虐待而有生命危险，但是老年人，就很可能处于一个在健康状况不良的脆弱情形下，遭受虐待后可能会带来生命危险。然而，当老年人死亡时，对其死因分析的态度并不像对待一个年轻的死者那样。受虐对象都有一些类似点，如害怕报复和羞辱，希望不要离开家庭或者保护施虐者、情绪困扰，以及在涉及到体能减弱的受虐者时，还会出现与受虐者沟通困难的情况。由于暴力事件，对受虐者和施虐等带来了很严重和类似的后果，对于这个领域的比较研究是很自然的。然而，尽管生命过程的相似性，对于不同的群体提供什么样的服务，以及什么样的干预策略是合适的，其方法有着深远的差异。需要关注到生态模型各个层次的不同之处以及各个层次之间的关联。老年人的社会状况与儿童和年轻妇女的社会状况是不同的。在任何年龄阶段，随着受虐妇女的数量的增多，老年体弱男子比年轻男子受虐的风险更大。

Theories of elder abuse and research need to focus on the extent of ageism, marginalization and sexism in society and their impact on abuse. Elder-abuse theories have for a long time ignored the views and perceptions of older persons themselves. Research increasingly includes older persons in designs of studies through participative and action research (43), or by gathering views and perceptions of older persons on their health needs and services (3), on the needs and perceptions of elders of minority ethnic groups (44â&#x20AC;&#x201C;47) and on possible interventions (7, 48). However, the development of such research is slow, sporadic and small- scale, requiring an urgent and ongoing effort to correct such a situation (49), which has a clear impact on the development of practice. Development of interprofessional theory that takes into account the interaction between the different levels of the ecological model may help in understanding the complexities of elder abuse and allow appropriate action to be taken.

Elder abuse and family violence Along with discrepancies regarding definitions, terminology and causes of elder abuse, there are controversies around which field elder abuse properly belongs to. Should elder abuse really be treated as a separate entity, or is it a branch of family violence, like child abuse and domestic violence? Similarities and differences with both child abuse and domestic violence are apparent both in the attitudes of the researchers and in public policies and services. Elder abuse is similar to and yet different from other types of family violence, and sufficient evidence suggests that a separate field of study is appropriate. However, this does not mean that elder abuse should be studied in isolation. Age alone does not define elder abuse. If, for example, a woman is a victim of intimate partner violence, just because she is over 65 years old does not constitute a case of elder abuse (14). Older women may in fact experience abuse at the hands of their partners throughout life. But as Dyer, Connolly & McFeeley (50) point out, whereas children and younger victims of domestic violence are generally healthy and not expected to die, older people, who may be suffering additional health problems, are more vulnerable to death caused by abuse. Nevertheless, when an older person dies, the cause of death is often not analysed as carefully as the death of a younger person. Victims of abuse share similar characteristics, such as fear of retaliation and stigmatization, desire not to leave home or desire to protect the abuser, emotional distress and, in cases involving persons with diminished capacity, difficulties in communicating the abuse. As violence has serious and similar consequences for human beings, both the abused and the abuser, it is natural that the fields of study are compared. However, despite the similarities across the life-course, there are profound differences of approach as to what kinds of interventions are appropriate and what services are available for the different groups (32, 51, 52). These differences need to be seen at each level of the ecological model, and especially in the interaction between them. The social situation of older persons is very different from that of children and younger women. Whereas higher numbers of women are abused at any age, older frail men are at much higher risk of abuse than younger men. 18

通常，比较虐老与儿童虐待，家长式的做法强调了用社会服务予以回应和保护。但是，老年人即使是那些最脆弱的和需要保护服务的老人，是一个拥有长期生活经历的成人。当老人受到虐待时，就应该像对待小孩子一样对待他的处境。早期的文献（Bennet等人的文章引用）将老年人虐待作为单独的一个领域的发展来研究，就像年龄歧视一样，其将老年人这一人群从成年人里面分离出来研究。但是，另外一方面，一些研究专家声称，正是由于老年人具体的特点，其需要独立的、专业的服务。此外，代表老年人的组织也倡导针对老年人需求的政策和服务，以回应社会大众化服务中的年龄歧视。因此，虽然老年人也是成人，但是由于其遭受的歧视和虐待的特定形式，需要专门对待和回应，以证明这一独立的研究领域。然而在实际操作中，在初级卫生保健水平，对不同年龄阶段发生虐待的筛查和干预或者转介，一般都是在一些相同的专业人士的掌控中，这些人通常需要针对老年人虐待放方面的具体的培训。现在，针对儿童虐待的干预计划和流程比性伴侣暴力和老年人虐待要更加详细明了。因此，执行人士可能会觉得所做的干预效果，由于缺乏清晰的政策和跨组织之间的有效联络，而大打折扣。而至于对老年人虐待筛查工具的研究，目前非常有限，对家庭暴力筛查工具的争论和对此争论的持理解态度可能会形成对虐待长者的研究和实践。

老年人虐待与性别虐待长者的性别虐待方面，以及与家庭暴力重叠的方面，有必要深入讨论。妇女比男人活得更长，几乎随处可见。2002年，欧洲60岁及以上的老人中，女性和男性的比例为1000:678。而在 80岁及以上的年龄中，世界范围的男女比例为<600:1000；而在发达国家中，80岁及以上的女性数量是男性数量的2倍多。虽然妇女具有长寿的优势，但是，在获取基本服务，诸如教育、卫生和社会保障上，女性比男性更容易经历家庭暴力和歧视，导致女性长期积累下来的不良的健康状况，再加上由于女性总体处于二等公民的社会地位，经常被忽视或忽略掉。因此，在分析老年妇女虐待方面，不仅要关注女性群体数量上比男性多这一事实，而且还要关注生命历程中，妇女可能会经历的歧视、压迫和虐待等社会事实。老年妇女，家庭暴力的受害者，绝大多数是那些忽视了他们所经历的家庭暴力和他们可以去获得的服务后的结果。关注遭受家庭暴力的项目一般只会为50岁以下的妇女提供服务，而老年医学和成人保护类服务，主要关注的是体弱或脆弱的老人。虽然，对家庭暴力和老年人虐待的研究会覆盖针对老年妇女的虐待研究，但是研究专家经常将老年妇女从其目标人群中隔离出来，这一行为会不断的强化“老年妇女是体弱无性”这一看法。但是，存在于情侣关系中的虐待风险因素是没有年龄差异的，并且报道过的大部分的案例中，老年人性伴侣的虐待实际上已经存在了很多年。

Often, a paternalistic approach comparing elder abuse to child abuse places the emphasis of the response on protection by social services. But older persons, even the frailest and in need of protection services, are adults with a long life experience. To infantilize their situation is considered by older persons as abuse (7). Earlier literature (as cited by Bennet et al. (32)) views the development of a separate field for elder abuse as ageist, as it separates older people from other adult citizens. On the other hand, some professionals claim that specific characteristics of old age require separate, specialized services (51). In addition, organizations that represent older people advocate for policies and services that are specific to their needs (53), in response to the ageist attitudes of the general services and of society in general. Therefore, while older persons are adults, the discrimination and specific forms of abuse they suffer require specific understanding and responses justifying a separate field of study. In practice, however, at the PHC level, the detection of abuse and interventions and/or referrals, at most ages, is generally at the hands of the same professionals who are in need of specific training to deal with elder abuse. Today, interventions and protocols for child abuse are much more defined than those for domestic violence and elder abuse (54, 55). Consequently, practitioners may feel that their intervention is undermined because of lack of clear policies and effective interagency liaison (54). As research on screening tools for elder abuse is currently very limited, an understanding of the debate and attitudes on screening tools for domestic violence may inform practice and research on elder abuse.

Elder abuse and gender The gender aspects of elder abuse and the overlaps with domestic violence in particular necessitate a deeper discussion. Women live longer than men almost everywhere. In 2002, there were 678 men for every 1000 women aged 60 years and over in Europe. At age 80 years and over, the world average was below 600 men for every 1000 women, while in developed countries women aged 80 years and over outnumbered men by more than two to one (1). Although women have the advantage of longevity, they are more likely than men to experience domestic violence and discrimination in access to basic services, such as education, health care and social security, resulting in a cumulative status of ill-health, which, due to womenâ&#x20AC;&#x2122;s second-class status, is often neglected or ignored (1). Therefore, it is critical to analyse the abuse of older women not only within the context of population numbers where women outnumber men but also in the context of a life-course of discrimination, oppression and abuse. Older women victims of domestic violence mostly fall between the cracks as generally they are overlooked by both the domestic violence and older peopleâ&#x20AC;&#x2122;s services (56â&#x20AC;&#x201C;58). Programmes for victims of domestic violence generally serve women under 50 years, while geriatric medicine and adult protection services have focused primarily on the frail and most vulnerable. Although both domestic violence and elder abuse research would be expected to cover the abuse of older women, researchers often exclude these victims from their target populations (56, 59), reinforcing the perception of older women as frail and sexless. But many of the risk factors present in abusive couple relationships are the same regardless of age, and the majority of reported abuse among older couples had in fact been going on for many years (60, 61). 20

“虐待长者”是一个性别中立的词，模糊了这样的一个事实——即大多数的受虐待者是女性，而施虐者，虽然不是绝对的，绝大部分是男性。过去的研究表明老年男性同样处于受虐的风险中，但是近期的研究表明这一现象只是发生在少数人中。比起女性来说，男性更容易施虐，美国的一个研究报告指出，老年妇女更容易成为所有虐待类型的受害者，除了被遗弃外。关于对比性伴侣虐待之后生活的研究与父母虐待的研究，发现，性伴侣更容易施行身体虐待，而成年子女更容易施行经济虐待。因此，研究虐待老人及其相关的干预势在必行。一些研究者提醒我们这个领域的不同的研究领域：家庭暴力运动是从美国草根女权主义组织中发展出来的，而虐待老人这一话题起源于健康和社会专业服务领域。这两个相似的话题其起源不同，常常用于解释为什么虐待老人传统上与照料体弱和依赖性强的老人更加相关联。然而，研究结果并不支持照料者压力或患者的依赖性等因素作为虐待老人的首要原因。事实上，在许多案例中，权力和控制的动态变化看起来与年轻受虐妇女的经历相似。有人指出，虐待长者的理论更应该放在性别关系的权力框架下以及女性被压迫的社会环境中——这一作法符合女权主义者的理论，而不是将其放入到年龄和家庭关系的框架下。但是，老年妇女遭受双重歧视：首先是女权运动将老年妇女排除在自己的业务范围外，并已经被指控为年龄歧视；另一方面，老年人虐待的研究已经被男性完成。正如干预家庭暴力中的年轻妇女一样，干预老年人虐待中老年妇女受虐工作通常也是非常复杂的。一个关于亲密伴侣暴力的定性研究，其目标人群是55岁以及以上的妇女，描述了为什么妇女总是处于受虐的关系中。其原因与年轻妇女受到虐待的原因一致，但是是老化、代代沉积、历史以及文化等种种原因的放大。离开施虐者对老年妇女来说，可能不是一个明智的选择：他们并不能找到像年轻妇女那样的有帮助的支持团体，因为他们有不同的生活经历，以及与儿童同住一室和/或去适应一些老年妇女的特殊需求，可能会导致受虐的老年妇女又重新回到施虐者身边。将虐待老人置于缺乏照顾的情况不仅掩盖了家庭暴力的实质问题，而且也引起了对照料者方法的关注和同情。通过了解照料体弱和不能自立的亲戚的困难和压力，很容易会因为过度识别“照料者”而将其置于受虐的风险，这种情形反映了以男性为主的宗法社会而忽视了女性的需要和安全。为了避免理解上的单一和偏颇，和为了确保所有的老年妇女，不管是独立或依赖，身体上或者精神上受损与否，需要照顾与否，都不能将性别和照料其孤立看待，而需要将其放在生态模式中分析。一个对性别方面真实的、基于权力分析，也将会将老年男性和女性都处于受虐的情况考虑在内。

The term “elder abuse” is gender-neutral, obscuring the fact that the majority of abused elders are women and offenders are usually, although not exclusively, men (8, 56, 62–64). Past studies have shown older men to be equally at risk (51), but currently these are in the minority. Men appear more likely than women to abuse (8, 64), and an incidence study conducted in the United States reported that older women were more likely to be the victims of all categories of abuse, except for abandonment (65). Studies comparing intimate partner violence in later life to parent abuse show that partners are more likely than adult children to physically abuse, whereas adult children are more likely than partners to abuse financially (63, 66). Thus, “engendering” the study and interventions on elder abuse is imperative. Some writers remind us of the different origins of the fields: the domestic violence movement grew out of grass-roots feminist organizations in the United States, whereas elder abuse grew out of the professional concerns of health and social services (32, 50, 56, 57, 64, 67). These separate origins of the movements are often used to explain why elder abuse has traditionally been related more closely with issues of caregiving for frail and dependent older persons. However, research does not support caregiver stress, or dependence, as primary causes of abuse (56, 68). In fact, in many cases, the dynamics of power and control appear to be similar to those experienced by younger abused women (59, 69, 70). It has been proposed that elder abuse should be examined more closely in the framework of power within gender relations and the oppression of women in society, rather than within the framework of age and family relations (71), in line with feminist theories. But older women have suffered double discrimination: on the one hand, the feminist movement has for too long excluded older women from their cause and has been accused of being ageist (67), and on the other hand, it has been claimed that most elder abuse research has been done by men (72). As with domestic violence against younger women, intervention with older women is very complex (73). A qualitative study of intimate partner violence among women aged 55 years and over (74) describes why women remain in abusive relationships. The reasons are the same as for younger women, but magnified as a result of ageing, generational cohort, historical and cultural reasons. Leaving the partner may not be an option for older women: they do not find support groups with younger women helpful, as they have different life experiences, and shelters filled with children and/or not adapted to some older women’s special needs may result in older women returning to their abusers. Placing elder abuse only within the context of inadequate care not only obscures the problem of domestic violence (56) but also raises concerns about the degree of “compassion” with the caregiver approach (75). By understanding how difficult and stressful it is to look after a frail and dependent relative, one is at risk of overidentification with the “caregiver” while leaving the abused at risk, a situation that mirrors identification with a male-dominated patriarchal society, where the safety and needs of women are overlooked. Gender and care cannot be seen in isolation and need to be analysed within the ecological model in order to avoid single or biased interpretations and to make sure that all older women, whether they are independent or dependent, physically and mentally able or impaired, are cared for. A truthful rights-based analysis of the gender aspects will also have to consider the instances in which older men are abused and in which women are also abusers (8, 32, 76). 22

人权方案正如载于1948年的人权宣言及之后的国际条约和国家人权法案所言，虐待的本质核心是丧失了起码的尊重以及被剥夺了基本人权。将虐待看作是一个人权问题则将关注焦点集中于政府的法律义务能否遵守签署的条约。预防老年人虐待是政府实现照料各自社会中所有人的职责的一部分。例如，英国的一个定性研究，从老年人的视角探索尊严问题，研究结果反映了老年人正在遭受没有尊严的方式对待。尊严被描述为“身份”、“人权”以及“自主性”。自主性是一种感知能力，能够对个人每天的生活、以及根据自己的生活规律和喜好做出掌控、适应和决策。普遍存在于社会各个部门，包括医疗卫生部门在内的年龄歧视，无论是在老年人虐待的原因方面还是在老年人虐待的发现、管理和预防方面，都是一个重要的因素。在准备2002年在马德里召开的联合国第二次老龄世界大会的联合国秘书长的报告中指出，性别歧视和年龄歧视是老年人虐待的重要因素；虐老应该被看做是在“更广泛的背景下的贫穷、机构不平等以及侵犯人权的行为”，这一行为不同程度地影响到了世界范围内的老年妇女。马德里国际老龄问题行动计划呼吁各级各个部门改变态度、政策和做法以确保世界各地的人们都能在增龄的过程中，作为公民充分享有安全、尊严和充分的权力。“马德里行动计划”是基于 1991年联合国大会通过并修改后的“联合国老年人原则”。这些原则阐述了老年人在独立、参与、照顾、自我充实和尊严等方面的权力。“为增加的年龄增添生活色彩”这一口号囊括了为所有年龄层次的人群创造一个正义社会的努力。在马德里世界卫生组织的第二次老龄问题世界研讨会中，联合国发起了积极老龄化的政策框架。积极老龄化的方法是基于对人权以及联合国老年人原则的认识。它不以老年人的需求为方法（将老年人作为被动的接受者）而将以“权力”为方法，承认并肯定老年人的权力，即在老化的过程中，人应该享受到同等的机会和公平的对待。这种方法支持人们应该行使自身参与社区生活方方面面的责任。虽然公众健康和人权领域常常会重叠，但是由于未将健康与人权元素相互整合，干预并不显成效。在使用法律框架、医疗保健和社会服务时，应该不分性别、民族、社会状态和年龄等，体现公平、强化全体人们的公民权力和人权。

A human rights approach At the very core of abuse are fundamental loss of respect and deprivation of basic human rights as set out in the Universal Declaration of Human Rights in 1948, consequent international treaties and national human rights acts. Recognizing abuse as a human-rights problem focuses attention on governments’ legal obligations to comply with signed treaties (77). The prevention of elder abuse is part of governments’ responsibilities to care for all people in their respective societies (7). For example, a qualitative study in the United Kingdom exploring older people’s perspectives on dignity reveals that older people are being treated in undignified ways. Dignity was described in terms of “identity”, “human rights” and “autonomy” (78). Autonomy is the perceived ability to control, cope with and make personal decisions about how one lives on a day-to-day basis, according to one’s own rules and preferences (1). Widespread ageism across all sectors of society, including the health care sector, can be recognized as an important factor both in the cause and in the identification, management and prevention of elder abuse. The United Nations Secretary-General’s Report (79) prepared for the 2002 United Nations Second World Assembly on Ageing in Madrid acknowledges the role of both sexism and ageism as contributing factors for elder abuse; abuse of older persons is seen within the “broader landscape of poverty, structural inequalities and human rights violations” that disproportionately affects older women worldwide. The Madrid International Plan of Action on Ageing (80) calls for changes in attitudes, policies and practices at all levels and in all sectors in order to ensure that people everywhere are able to age with security and dignity, as citizens with full rights. The Madrid Plan of Action is based on the United Nations Principles for Older Persons adopted in 1991 by the United Nations General Assembly (81). These principles elaborate the rights of older persons in the areas of independence, participation, care, self-fulfilment and dignity. The slogan “To add life to the years that have been added to life” encapsulates the totality of efforts towards a just society for all ages. During the United Nations Second World Assembly on Ageing in Madrid, WHO launched its policy framework on active ageing (1). The active ageing approach is based on the recognition of human rights and the United Nations Principles of Older Persons. It shifts away from a “needs-based” approach (which assumes that older people are passive targets) to a “rights-based” approach that recognizes the rights of people to equality of opportunity and treatment in all aspects of life as they grow older. It supports their responsibility to exercise their participation in all aspects of community life. Although the domains of public health and human rights frequently overlap, effective interventions are hampered by the lack of an active integration of human-rights principles in health care (77). Legal frameworks, health care and social services need to be applied with a strong sense of equity, reinforcing the civil and human rights of all people, regardless of sex, ethnic origin, socioeconomic status and age.

3. 筛查定义世卫组织癌症项目网站将筛查定义为：“通过测试手段、考查或者其他可以迅速应用的程序，推定未确定的疾病或者缺陷”。还声称，“筛选的成功取决于有足够数量的人员能够进行筛查测试，以及在设施条件具备的情况下，可以进行后续的诊断、治疗和跟进。” 英国国家审查委员会将“筛查”定义为：这是一种公众卫生服务，即在对特定人群的成员，这些成员不一定意识到自身所处的潜在危险，或者在遭受某种疾病或其并发症的影响，对其进行问诊或者特定的筛查，以确定这些人中那些人会更容易通过进一步的检查或者治疗达到减少某种疾病或者其并发症的危害。根据上述的定义，筛查是一种公共卫生服务，对其考核应该在严谨的科学指导下进行。对一般的筛查的评估通常是根据他们的正面和负面的预测价值以及其敏感性和特异性进行的。敏感性指的是在诊断某人患有某个疾病时，筛查工具的有效性；而特异性指的是在发现某人没有特定疾病时筛查工具的有效性。筛查工具的目的是为了更高的灵敏度和特异性，以便于做出正确的判断结果。美国预防服务工作队对暴力筛查的定义为：在卫生保健场所进行的，对无症状的人进行相关的危险评估，以判断其有没有遭受家庭或者亲密伴侣的暴力伤害。明显遭受家庭暴力伤害的个人需要的是进行诊断而不是筛查、评估。普遍的筛查意味着对每个人进行评估；选择性的筛查指的是对那些满足特定标准的目标人群进行评估。针对整个人群的潜在风险的筛查，其将个人置于“提高可能性”小组做进一步的评估，要重点与个案发现或者诊断评估相区别，虐老实际名称的成立是基于虐待指标不断提高。这两种方法在研究和实践中，包括了不同层次的严谨性和调查。

3. Screening Definitions The WHO Cancer Programme website (82) defines screening as the “presumptive identification of unrecognized disease or defects by means of tests, examinations, or other procedures that can be applied rapidly”. It also claims that “the success of screening depends on having sufficient numbers of personnel to perform the screening tests and on the availability of facilities that can undertake subsequent diagnosis, treatment, and follow-up”. The United Kingdom National Screening Committee (83) describes screening as: a public health service in which members of a defined population, who do not necessarily perceive they are at risk of, or are already affected by a disease or its complications, are asked a question or offered a test, to identify those individuals who are more likely to be helped than harmed by further tests or treatment to reduce the risk of a disease or its complications. Screening, according to the above definition, is a public health service, and the appraisal of screening tests is done with scientific rigour. Screening tests are generally evaluated according to their predictive values of positive and negative and their sensitivity and specificity. Sensitivity refers to the effectiveness of a test in detecting those who suffer the condition and specificity to the effectiveness of the test in recognizing those that are free of the condition (82). Screening tests aim for a high sensitivity and specificity, which will provide the likelihood of a correct result. The United States Preventive Services Task Force (26) defines screening for violence as: assessment of current harm or risk of harm from family and intimate partner violence in asymptomatic persons in a health care setting. Individuals presenting with injuries from family violence undergo a diagnostic, not screening, evaluation. Universal screening means assessing everyone; selective screening indicates that only those who meet specific criteria are assessed. It is important to distinguish between screening, directed at the entire population potentially at risk, whereby individuals are put into an “elevated probability” group for further evaluation, and case finding, or diagnostic evaluation whereby an actual designation of elder abuse is made based on indicators raising the suspicion of abuse. In both research and practice, the two approaches encompass different levels of rigour and investigation (14, 84).

虽然公共卫生领域的筛查是一个已经被定义好的、以证据为基础的话题，但是在文学中，这一词汇有很多不同的用途和解释。这一词汇经常会被乱用，而且会时而混淆争论。在暴力领域，筛查一般指的是专业人员检查受虐待的对象和排除非受虐待的对象的行为。对家庭暴力和虐老的筛查对研究方法造成了挑战，使其难以符合公众健康的定义。因此，一方面，他会被质疑一直以来对“说服”国家执行筛查所作出的努力，另外一方面，也会对为什么对筛查狭隘的定义在询证医学的范围内产生质疑。 “筛选”一词的使用，是不同专业之间差异性的表达，因为各行都有对其特定的语言或“行话”，这就加重了确定虐老应该属于哪个领域的困难。通过对术语的医学化处理，卫生保健的层次性就表现的越来越明显了；也就是说，将医学模式用于公共卫生领域，比其他专业，更具有优势和力度。为了催动与生态模型的跨学科合作，沟通所需要的语言势必需要澄清，以便于所有的专业人士明白其中的利害关系，从而一起努力找到解决方案。

利与弊筛查方案的基本原则是 “利多于弊”。在绝大多数国家使用的评估筛查方案的标准如下： l

筛查的条件应是一个重要的健康问题，这个健康问题已经得到了充分研究，并具有已知的危险因素或指标。

l

试验应简单，安全和经过验证；

l

筛查过程应该是大家都可以接受的；

l

应该有后续跟进的干预措施；

l

必须有可靠的随机对照试验证实通过筛查可以降低死亡率或发病率，并具有成本效益；

l

必须与足够的人员储备；

l

应该有证据证实完整的筛查项目（从接受测试到后期的干预）是“临床上，社会和伦理上都可以被专业人士和公众接受的” 这三个选择的顺序依次是：“临床”第一，“社会”第二，“伦理”第三——再次体现了至高

无上的临床医疗模式。筛查，被描述为“一个双刃剑，有时心怀好意，但同时却有笨拙的一面”，比如，对癌症诸如此类的疾病筛查经常被批判。由于筛查可能只会惠及少数的受众，同时可能会伤害及其他的人，所以，当引入一个国家筛查项目的时候，其受益面必须要远远超过负面的影响。

Although screening in public health is a well- defined evidence-based issue, throughout the literature one encounters different uses and interpretations. The term is often used indiscriminately and may at times confuse the debate. In the field of violence, screening is generally referred to as the action by which professionals detect abused individuals while excluding (screening out) the non-abused individuals. Screening for domestic violence and elder abuse pose methodological challenges that make it difficult to match the public health definition. Therefore, it could be questioned on the one hand why efforts are invested in trying to “convince’ national task forces to recommend such screening. But on the other hand, the question could be why screening should be defined only in the narrow sense of evidence-based medicine. The uses of the term “screening” are one expression of the differences between professions, each with their corresponding language or “jargon”, compounding the difficulty in determining where elder abuse belongs. Through the medicalization of terms, the hierarchical nature of health care becomes apparent; that is, the medical model used in public health is more dominant and more powerful than others. In order to advance interdisciplinary cooperation in line with the ecological model, communication and language are key elements that need to be clarified so that all the professionals involved understand what is at stake and can work together towards solutions.

Benefit versus harm The basic principle of screening programmes is that they “do more good than harm” (22). Among the criteria used by most countries to assess a screening programme are the following: l

l l

l

The condition should be an important health problem, well understood and with a known risk factor, or indicator. The test should be simple, safe and validated The screening test should be acceptable to the population. There should be available effective interventions to follow up. There must be evidence from reliable randomized controlled trials that the screening programme reduces mortality or morbidity and is cost effective. There are adequate staff available. There should be evidence that the complete screening programme (from test to intervention) is “clinically, socially and ethically acceptable to health professionals and the public” (85).

The choice in the order of the words – “clinically” first “socially” second and “ethical” third – reflects again the supremacy of the clinical medical model. Screening has been described as “a double- edged sword, sometimes used clumsily by the wellintended” (86) as the value of screening for diseases such as cancer and others is also debated (87). Since screening may benefit a minority and possibly harm others, it is believed that the benefits must outweigh the risks before introducing a national screening programme (88).

美国预防服务工作队清楚地表明，对利和弊权衡的评估完全是基于证据的质量和规模。通过文献回顾，美国预防服务工作队2004年的建议中，并未发现有任何研究证实筛查或者干预会带来负面的影响。专责小组声称，假阴性的测试结果，可能阻止医生进一步寻求相关的病史，并将那些真正处于危险因素中个人排除在外。而另外一方面，假阳性的测试结果，可能会给受害人带来不良的结果以及心理上的困扰，可能会导致家庭关系紧张，失去个人住宅，以及经济资源和自主权的丧失。然而，在医学界内，循证医学也一直备受争议。有声音指出，患者的个人喜好、心理社会因素、以及舒适和放心，在人道主义护理过程中是做临床决策时要考虑的必要因素。并不是基于最佳证据而实践的基本原则遭到批评，而是完全使用相同的“证据”和方法——比如随机对照试验—— 的教条主义，哪怕这些方法显然不总是适合所有的环境和条件。当涉及到虐待问题时，损害-效益范例需要从人文观点来看，无论是以病人为中心，还是以医生为中心，都应该需要推进良好的实践。

筛查老年人虐待筛查虐老的几个工具，几乎完全是由北美开发出来的。在几种不同的工具中，很少有几个被广泛用于临床，认为这些筛查工具不准确，特异性不够，缺乏灵敏度或不够可靠，因此不能被正式通过或推荐。尽管缺乏被广泛接受的工具，美国医学协会呼吁所有的临床机构遵循常规的筛查流程。对初级卫生保健机构来说，因为缺乏验证工具，如果比较或者评价这些工具在初次测试之外的场所的实用性就比较困难。但是，重要的是，这些筛查工具为将来进一步的研究提供了依据。通过识别高危因素已经成为检测虐老的主要途径。在过去十年中发表的研究成果中，多次描述了几个可能会增加虐待的危险因素。与风险评估相关的工作的复杂性，突出了医生的诊断在识别虐待方面的关键作用。McCreadie等在英国和伯明翰对全科医生进行了两项调查，发现只有不到一半的全科医生在去年的一年中诊断过一例虐老。这些研究透漏出，全科医生在一个长期的医患关系中，特别是在家访时，具备至少5个危险因素的个人知识，对于识别和诊断虐老非常有帮助。

The United States Preventive Services Task Force (26) makes clear that it evaluates the balance of benefits and harms based exclusively on the quality and magnitude of the evidence. The literature review (25) that led to the Task Force’s 2004 recommendation did not find any studies that provide data on possible adverse effects of screening or interventions. The Task Force claims that falsenegative tests may discourage clinicians from seeking further history and prevent identification of those individuals who are truly at risk. False-positive tests, on the other hand, can lead to labelling and punitive attitudes as well as psychological distress, and might lead to family tension, loss of personal residence and financial resources and loss of autonomy for the victim. However, evidence-based medicine is also debated from within the medical profession. There are voices declaring that personal preferences, psychosocial factors, comfort and reassurance, for patients are essential elements of clinical decisions in humanistic care (89, 90). It is not the principle of practice based on the best evidence that is criticized but rather the dogmatism of applying the same “evidence” and approaches, such as randomized control trials, to all settings and conditions when it is apparent that they do not always fit. When dealing with abuse, the harm– benefit paradigm needs to be seen from a humanistic view, both patient- and practitioner-centred, in order to advance good practice.

Detecting elder abuse Several tools for detecting elder abuse have been developed, almost exclusively in North America. Among the various tools, few are accepted for wide application in clinical settings. They are regarded as being not accurate, or specific, or sensitive or reliable enough to be officially adopted and recommended (91). Despite the lack of widely accepted tools, the American Medical Association calls on all clinical settings to follow a routine screening protocol (16). In the absence of validated tools for PHC settings, it is difficult to make comparisons or evaluate their applicability in settings other than that where it was tested in the first place. However, it is important to mention them as they provide the evidence on which future research should build. The main approach to detection of elder abuse has been through identifying high-risk factors. Research published in the past decade has repeatedly described several risk factors that appear to increase the likelihood of abuse (62, 84, 92-94). The complexity of the task related to risk assessment emphasizes the crucial role of the doctor’s judgement in identifying abuse. Two surveys of general practitioners conducted by McCreadie et al. (95) in London and Birmingham, England, revealed that less than half the general practitioners had identified a case of elder abuse in the previous year. These studies seem to indicate that general practitioners’ personal knowledge of at least five risk factors paired with a long-term doctor-patient relationship, especially through home visiting, facilitates diagnosis of abuse.

一般来说，虐老的主要危险因素包括： l

对受虐人和/或其家庭的社会隔离；

l

受害者的脆弱，失能以及认知功能的减退；

l

施虐者的疾病状况，比如酒精或者其他物质滥用，认知功能缺陷以及精神问题等；

l

照料者压力或者易怒；

l

受虐者对施虐者的依赖（比如，照料者就是施虐者）或者施虐者对受虐者的依赖（比如，已成年晚辈对长辈经济上的依赖是虐待者）。上面列出的危险因素，是尽可能较早的评定，性别中立，而未将具有独立能力的老人受到虐待

的可能性考虑在内。近期对绝经后妇女虐待率的研究结果表明，在妇女增龄的同时，对老年妇女的虐待风险因素有一个过度阶段。只要妇女保持独立，那么虐待老人的危险因素就像家庭暴力的危险因素。如果她变得对其他人有依赖了，那么对她们来说，风险因素就会变得跟照料者虐待和忽视一样。非常重要的是需要对老年妇女遭受双重危险因素虐待的程度进行研究。由于老年人可能会出现由于老化的多种体征和症状，如皮肤脆弱，或跌倒，或意识混乱等，因此，在某个特定的场景中考虑更多的影响因素，和为了给病人提供安全、优化的照护服务以及避免误解，非常需要保持警戒状态。除了自身的危险因素以外，肢体功能障碍可能会大大降低自我保护的能力。增强病人社会心理现状的意识，将有助于理解预测虐待现象的重要的背景因素。

既有的筛查虐老工具介绍已发表的有效使用的工具很少存在。其中一个是“Hwalek Sengstock 虐老筛查工具 (HSEAST)”，它处理的就是各种虐老类型，并且是一份自测量表。这个工具包括了三个领域的15 个条目：对个人人权的侵犯或者直接虐待，脆弱的特点，以及潜在的虐待情形。Reis和Nahmiash 已经完成了三个经过验证的筛查工具： l

简易虐老筛查工具是一个由5个问题组成的简单工具。评估者根据这套评估工具就可以现场完成对病人的评估。

l

照料者虐待倾向筛查是由8个针对照料者的问题组成。他是用于检测认知功能障碍的病人的安全状况。他并不是直接针对病人。虽然，这个工具可以帮助发现可疑对象的虐待行为，但是他只有照料者模型，而忽略了病人的自主权。

The main risk factors for elder abuse are generally considered to be: l l l

l l

social isolation of the abused person and/or the family; frailty of the victim, functional disability and cognitive impairment; pathology of the abuser, such as alcohol or other substance abuse, cognitive impairment and mental-health problems; caregiver stress or anger 14 dependence of the victim on the abuser (e.g. the caregiver is the abuser) or dependence of the abuser on the victim (e.g. an adult child with financial dependence on the parent is the abuser).

The risk factors listed above are as critiqued earlier, gender-neutral and do not consider the possibility of non-dependent older persons being abused. Findings of the one study to date on the incidence of abuse among postmenopausal women suggest that there is a transition in the risk factors for abuse of women as they age. As long as the woman remains independent, risk factors are like those for domestic violence; if she becomes dependent, then the risk factors become those of caregiver abuse and neglect (96). It would be important to research to what extent older women do in fact suffer the double burden of risk factors. Since older persons may present signs and symptoms of a multiplicity of factors due to ageing, such as frail skin, or a fall, or confusion, it is very important to always think broadly in each circumstance and to be alert in order to provide for the safety of the patient and optimal care and to avoid false accusations (5, 34). Functional impairment, in addition to being a risk factor in itself, may diminish greatly the capacity of older people to defend themselves (92). An increased awareness of the psychosocial reality of the patient will assist in understanding the contextual factors that may be strong predictors of abuse.

Existing tools for detecting elder abuse Few published validated instruments exist. One such tool is the Hwalek-Sengstock Elder Abuse Screening Test (HSEAST) (25, 97), which addresses the various types of elder abuse and is a selfreport measure. The instrument has 15 items in three domains: violation of personal rights or direct abuse, characteristics of vulnerability, and potentially abusive situations. Three validated instruments have been developed by Reis & Nahmiash: l

l

The Brief Abuse Screen for the Elderly (BASE) (68) is a simple tool comprising five brief questions. The respondent here is the practitioner following an assessment of the patient. The Caregiver Abuse Screen (CASE) (98) consists of eight questions to caregivers. It is used to detect abuse in cognitively impaired adults. It does not address the patient directly. Although this tool may facilitate the difficult task of interviewing a suspected abuser, it assumes only the caregiver model and ignores the autonomy of the patient.

l

虐待筛查指标由48个问题指标组成，由卫生专业人士基于一个全面的家庭评估完成。这个工具直接面对目标人群，主要是基于专业人士的评估技能。比如，一些由专家来完成的问题是关于病人是不是有行为问题，酒精或者药物问题或者既有的社会关系不良好。这些显然不是由一个临床设施的筛查工具，而是被公认为一个潜在的良好的科研工具。老年人评估工具包括了对老年人的一般概况评估、具体的生活环境评估、社会医疗评估和生活

独立性水平评估等。目前这一评估工具已经被用于虐老评估团队和急症室的护士。最近，为了便于深入评估和将可疑的受虐者转介到合适的社区服务（比如社会工作者），从而达到建立一个合理的虐老可疑水平，虐老可疑指数应运而生。其支持理论就是依靠一个简单的工具，这个工具可以给予病人权限去评论，并且可以怀疑一定程度的“虐待”而不一定是诊断。其目标使用者是那些全科医生、内科医生和老年医学专家以及社工、护士等，意图是扩大虐待筛查工具的使用。这个工具由5个简短的问题组成，目标人群是老年人，由医生来完成测试。通过上述描述的工具，筛查和评估方法上的差异以及其基本支持理论是显而易见的。只有两个工具（H-S/EAST和EASI）用直接的针对老人设计问题。在其他筛查工具设计中，照料者模型的沉重影响是显而易见的。下页的表格列出了上述提及的很多个工具的简单对照。在表格中的验证场所列代表了最初使用工具、完全的评估结果的对比，目的是验证或者不验证工具。对筛选工具普遍接受的评价只在那些参与本研究的专业人士中间进行。还没有人对该工具在老年人群中的接受程度做评估研究。事实上，使用筛检工具的好处之一是，为老人提供服务的供应商的虐老意识的提升，但是，没有针对老年人，即筛查对象，在工具接受方面的评估，不仅是有违背筛查的原则的，而且是有违“以人权为基础的”筛查方法的。奎格利（Quigley）建议，执行人员要反思，为了实现一个公平的虐老筛选机制，可疑的虐老个案是否涉及违反人权要求。虐待老人发生在特定环境中，如果没有对虐老问题的生物/心理-社会方面的广泛评估，任何筛查或者评估工具的作用都是有限性。有效的筛查工具将从一开始就使用多学科的方法和参与式的研究。在设计和修正筛选工具中涉及的学科越多，参与的人越多，那么筛选工具就会被专业人士和病人接受。他将会提高不同行业之间在操作层面的转介和干预。

lď Ź

The Indicators of Abuse Screen (IOA) (68) is a 48-point checklist of problem indicators for abuse that is completed by health care professionals in the context of a comprehensive home assessment. The tool addresses the patient directly. The tool builds on the professionalâ&#x20AC;&#x2122;s assessment skills. For example, some of the items to be checked by the professional are whether the patient has behavioural problems, alcohol or medication problems or poor current relationships. This is clearly not a screening tool for the clinical setting, but it has been recognized as a potentially good research instrument (28).

The Elder Assessment Instrument (EAI) (99) includes a general assessment of the older person as well as specific physical, social and medical assessments and level of independence in lifestyle. It has been used by elder abuse teams and nurses in the emergency departments. More recently, the Elder Abuse Suspicion Index (EASI) (100) was developed with the goal of establishing a reasonable level of suspicion in order to justify referral to an appropriate community service (such as a social worker) for in-depth assessment. The theory behind this is that a simple tool can grant the patient permission to talk and can generate a level of suspicion and not necessarily a diagnosis. It is aimed at general practitioners, general internists and geriatricians with the intention to expand and test it also with social workers and nurses. It is a short five-question tool directed at the older person, with one observation item to be completed by the doctor. Through the tools described, the difference of approaches towards screening and assessment, and the underlying theories, are noticeable. Only two tools (H-S/EAST and EASI) target the older person with direct questions. The heavy influence of the caregiver model in the design of the other tools is evident. Table 2 on the next page shows a simple comparison of the tools mentioned above. The validation column in the table represents the setting where a thorough assessment was performed to compare the results with those from the setting where the tool was originally used in order to validate, or not, the tool. Evaluations of the general acceptability of the tool were performed only with the professionals who participated in the studies. No study evaluated acceptability of the tools by older persons. One of the benefits of using screening tools is, indeed, the raising awareness of elder abuse among service providers, but non evaluation of the acceptability by the patients themselves is not only is against the principles of screening, but also against a rights- based approach. Quigley (101) proposes that practitioners ask themselves whether suspected cases of abuse involve violation of human rights as a requirement to achieving a fair screening system for elder abuse. Elder abuse takes place within a context and, without a comprehensive assessment of the bio/ psycho-social context of elder abuse, any screening or assessment instrument has significant limitations (28). An effective tool would be one that uses an interdisciplinary approach and participatory research from the start of its development. The more disciplines, and the more older people are involved in the design and refinement of a tool, the better the tool will be accepted by both professionals and patients. It will also improve the interprofessional practice on referrals and interventions.

工具

特点

验证环境

H-S/EAST(Hwalek-

15个条目

住在公共服务场所中的100

Sengstock 由Nelson等人引

老年人是目标人群

个老人

用的虐老筛查)

识别被虐待或者忽视的情形

BASE简易虐老筛查工具

5个条目

健康和社会服务机构中案例

由经过培训的执行人填写

的家庭评估

用于评估照料者或者其他老人的虐待倾向 CASE 照料者虐待筛查

8个条目（措辞上不责备）

44个已知的攻击性照料者

照料者作为评估对象

和45个非攻击性照料者接

识别潜在的、有虐待倾向的照料者

受了来自社会服务中心的照护

IOA虐待筛查指标

29个条目

健康和社会服务机构中341

经过培训的执行人评估照料者和老

个案例的家庭评估(55岁或

人

者以上)

发现和识别健康和社会服务客户中的虐待现象 EAI老年人评估工具（修订

44个条目

急诊护士

版）

由经过培训的护士操作，旨在发现那些有高危受虐因素或者被忽视而应该得到转介的个人，而进行进一步评估

EASI虐老可疑指数

6个条目（由5个问题组成和一个观

由社工评估的663个家庭评

察）

估

老年人是调查对象为了评估虐待的可能性表2：侦测老年人虐待工具的介绍

Tool

Characteristics

Validation setting

H-S/EAST Hwalek-Sengstock Elder Abuse Screening Test as cited by Nelson et al.

15 items Older person is the respondent. To identify situations likely to be or become abusive or neglectful.

100 elders living in public housing

BASE The Brief Abuse Screen for the Elderly

Five items Filled by trained practitioner. To assess likelihood of abuse with caregiver/elder.

Home assessment of health and social services agency cases.

CASE Caregiver Abuse Screen

Eight items (specifically worded to be non-blaming). Caregiver as respondent. To identify potentially abusive caregivers.

44 known abusive caregivers and 45 nonabusive caregivers receiving care from a social services centre.

IOA Indicators of Abuse Screen

29 items Trained practitioner to assess caregiver and elder. To identify abuse among health and social services clients.

Home assessment of 341 health and social services agency cases (age 55 and older).

EAI Elder Assessment Instrument (revised)

44 items Trained nurses to identify individuals at high risk of abuse or neglect who should be referred for further assessment.

Acute care.

EASI Elder Abuse Suspicion Index

Six items (five questions and one observation) Older person as respondent. To assess likelihood of abuse.

Home assessment of 663 respondents by social workers.

Table 2: Examples of tools for detecting elder abuse

争论：要不要筛查？美国预防服务工作组未能找到足够的证据来界定筛查家庭和亲密伴侣对儿童、对妇女或者其他老人的暴力的利与弊的平衡点，因此，并没有推荐这种或者那种方法。英国国家审查委员会在2004 年简短的声明中，更加明确了“不应该”开始对家庭暴力的筛查。英国国家审查委员会的决定基于拉姆齐等人的报告。英国医学杂志的文章“医疗保健专业人士要不要对妇女进行家庭暴力筛查？”，总结了2001年考核的证据。筛查委员会的陈述和证据，引起了相应的文字回应，在科学杂志上发表了很多关于同意和反对筛查相关的社论和文章。英国的国家审查委员会和建议所依据的证据，并不是全部涉及到老年人虐待，也没有提及与家庭暴力相关的老年妇女。拉姆齐等人的系统回顾，侧重于三个标准： l

妇女和专业人士是不是能够接受筛查；

l

在卫生护理场所有没有针对发现的受虐妇女的有效处理或干预；

l

筛查测试会不会增加发现受虐妇女的发现率文献回顾显示，大部分妇女认为筛查是可以接受的；但是，只有一小部分初级卫生保健工作者

觉得筛查是可以接受的。这一事实反映了对病人卫生保健需求的回应程度。目前没有发现随机对照研究在干预措施方面的进展。虽然研究发现当筛查项目开展后，虐老的发现率的确有上升，但是，系统文献回顾报告的作者却引用了一个比较负面的“稍微缓慢的”一次来表达，因此，并不是对推荐筛查有帮助。但是，稍微缓慢的增长也是一种增长，非常有趣的是，对已成败局的的描述，如果关注其框架，仍然可以有其成功一面的解释。大部分来自美国的研究还是很符合拉姆齐等的研究标准的。因为实施更多的研究是非常有必要的，因此，缺乏行动建议可能会在执行过程中带来负面的影响，并且产生一种厌倦任务的行为，就像由于缺乏合适的研究设计，初级照护任务经常被忽视一样。通过将来合适的科学研究来澄清对家庭暴力筛查的问题的解决方案，这种理念——没有必要现在就开始——似乎会不会带来专业人士的即刻行动。家庭暴力对妇女的危害性可能比其他人更大，对这个健康问题的例行检查仍然没有常规进行。在指责不好的研究和证据不足方面，事实上是病人此时此刻正在遭受痛苦，正在受到惩罚。

Should we screen? The debate The United States Preventive Services Task Force (25, 26) could not find enough evidence to determine the balance between the benefit and harm of screening for family and intimate partner violence among children, women or older adults and, therefore, did not recommend one way or the other. The United Kingdom National Screening Committee was more categorical in its short 2004 statement that screening for domestic violence “should not” be introduced (24). The United Kingdom National Screening Committee based its decision on a report commissioned from Ramsay et al. (22). The British Medical Journal article “Should health care professionals screen women for domestic violence?” (23) is the summary of the 2001 appraisal of the evidence. The statements by the screening commissions and the evidence they used triggered letters with responses, editorials and articles published in scientific journals arguing both for and against screening (102–104). The United Kingdom National Screening Committee, and the evidence on which it based the recommendation, does not relate at all to elder abuse; nor does it mention older women in relation to domestic violence. The systematic review by Ramsey et al. (22) focuses on three criteria: l l

l

whether screening is acceptable to women and to health professionals; whether there are effective treatments or interventions for women identified in health care settings; whether screening programmes increase the proportion of women identified.

The reviewed studies show that most women find screening acceptable; however, only a minority of PHC practitioners find it acceptable. This fact raises some concerns about the level of responsiveness of health care to the needs of the patients. Regarding interventions studies, no randomized control study was identified. Although a small increase in the rate of identification when screening programmes are in place is revealed by the studies, the authors of the systematic review quote it in a negative way as “only modest” therefore not justifying a recommendation for screening. But a modest increase is still an increase; it is interesting to note the framing of statements that imply defeat when in fact they could be interpreted as a success. Most of the studies that met the inclusion criteria for the review by Ramsey et al. (20) were from the United States. As it becomes imperative for more research to be performed, a recommendation for lack of action may have negative consequences in practice and develop anti-task behaviours (105) as the primary task of care is sometimes forgotten behind the lack of properly designed studies. The belief that the solutions clarifying the issues on screening for family violence will be found only through future proper scientific research – which is not necessarily in the pipeline – seems to exempt professionals from immediate action. Domestic violence is the healthcare problem that probably endangers women more than any other and still is the one for which routine screening does not take place (106). In blaming bad studies and the lack of evidence, it is in fact the patients, suffering here and now, who are being punished. 38

正如公共卫生领域对筛查的定义：标准化的测试或者问题，不随着时间或者地点而改变，并且具有很好的敏感性去发现特定的影响因素和提供一个有效的反应。其中对家庭暴力进行筛查的项目评估的一个问题是，尤其是在英国，评估的纳入标准经常与健康卫生机构隔离开，没有考虑到更广泛的社会网络和社区服务。虽然对在卫生机构进行筛查存在一定的争议，但是评估结果需要跟进，并且是需要在跨专业反馈的背景下，超越卫生机构的范围。拉赫斯对美国预防服务工作队挑衅性的反应，反应了上述的问题： ……临床医生经常碰到的一些情况，对循证医学机械般的投入，冒着某些行医方面非人性化的危险。任何医生，只要将受害人从被虐待的环境中解救出来，就会明白这点。在这种情况下，如果我们有工具可以衡量“规模效应”，那其带来的益处就会让控制高血压或者糖尿病带来的好处相形逊色。 Coker(108)认为美国预防工作组对于普遍应用需要科学证据的论辩是一个对于合法性的质疑，提出了在暴力研究中什么才是有道德的这个问题。循证医学认为在没有合适的随机试验的证据支持下实施筛查是不道德的，而进行试验的唯一方法是通过设立一个干预组和一个对照组。其他意见认为用对照组进行随机试验是不道德的，因为这代表有意识地对一整个群体不予评定或者不予干预。 Coker反过来质问医疗当局，认为应当投资更多的资源来实行更多研究，他声称既然现在做筛查的医疗护理提供者如此之少，随机试验依然可以在合乎伦理的情况下进行，如果所有医疗护理设施都掌握广泛可用并且容易了解的社区资源信息，比如在候诊室和盥洗室(108)。关于伦理问题的讨论延伸到保密、报告和自主权问题，显示了所牵涉的问题的敏感与复杂程度，而事实上就要求更多的行动而不是相反。关键问题可能不是要不要筛查，而是如何通过适当的交流与妥协找到相互对立的观点间的平衡。科学严谨以及人文关怀需要共同存在并且相辅相成。

Screening, as defined in public health, refers to a standardized test or question that does not change from place to place and that has the ability to identify a condition with good sensibility and to provide an effective response (107). One of the problems of the evaluation of screening programmes for domestic violence, especially that in the United Kingdom (22, 23), is that the inclusion criteria for evaluation are often set in isolation within health care settings without considering the wider social network and community services. While the issue of debate is indeed screening at health care settings, the evaluation of outcomes needs to be followed up beyond health care settings and within the context of interprofessional feedback. Lachsâ&#x20AC;&#x2122; provocative response to the United States Preventive Services Task Force reflects the issues described (27): ...for some conditions that clinicians regularly encounter, robotic devotion to evidence- based medicine risks dehumanizing certain aspects of doctoring. Any clinician who has extricated a family violence victim from an abusive situation understands this. If we had the tools to measure an â&#x20AC;&#x153;effect sizeâ&#x20AC;? in such situations, it would make the benefits of controlling hypertension or diabetes look paltry by comparison. The United States Preventive Services Task Force argument requiring scientific proof of generalizability is seen by Coker (108) as a legitimate challenge raising the questions of what is ethical in violence research. Evidence- based medicine considers it unethical to perform screening without having proper evidence of randomized trials for which the only way to perform a trial is through an intervention group and a control group. Others consider it unethical to perform randomized trials using control groups, i.e. consciously not assessing or offering interventions to a whole group. Coker challenges in turn the medical establishment to invest resources and conduct more research, claiming that since so few health care providers currently do screen, randomization of settings may still be conducted ethically, provided that all health care settings have information about community resources widely available and easy to see, such as in waiting rooms and toilets (108). This discussion on ethics extends to issues of confidentiality, reporting and autonomy, demonstrating the degree of sensitivity and complexity involved and that in fact require an increase in action rather than the opposite. The question may not be whether to screen but how to find the balance between opposing points of view, through proper communication and compromise. Scientific rigour and humanistic care need to exist side by side and be mutually beneficial.

基层医疗护理年轻女性参加产前服务比其他服务更多。尽管更年期以及老年女性也参加妇科服务(109)，但基层医疗护理可能对许多受到虐待的人来说是唯一在生育年龄之后还会接触到的地方。受到虐待的女性的妇科、中央神经系统、结肠激惹和压力相关问题以及慢性疼痛比如头痛或者背痛的发生率会增加50-70%(110)；然而，一般被认为是最明显的虐待标识的伤口其实可能无法鉴别出正忍受和虐待有关的长期问题的女性(108,110-114)。有资料显示绝经后的女性受到虐待的比率和较年轻的女性相似，导致了对她们健康的严重威胁(96)。有证据显示老年人虐待在死亡率和致病率原因中都占有一块不小的份额。Lachs等人所作的一篇重要的被广泛引用的纵向研究(6)显示了老年人虐待在逐渐增加的死亡率中所起的独立影响。这个研究强调了医生在鉴别风险人群、启动干预以及联络社区服务方面的重要作用，因为早期的发现与合适的跨领域应对能够拯救生命。有证据显示受虐待的人比不受虐待的人更频繁地访问基层医疗护理设施(109,115-118)。在英国，超过90%的人口在近五年内联系过基层医疗护理服务(119)。年龄越大罹患慢性疾病的风险就越大(1)，因此基层医疗护理成为了习惯的自然而然的去处，也暗示了信任关系的持续加深。老年人虐待无法被处理除非被侦测到。尽管基层医疗护理人员处在鉴别暴力和老年人虐待的理想位置，但是举例来说在美国仅有2%的报告案件来自医生(120)；虽然努力改进侦测，只有不到10%的基层医疗护理医生在常规门诊中例行筛查家庭暴力(115)。

例行筛查还是例行询问？词语的重要含义不应该被低估。术语“筛查”在公共卫生领域有具体的含义，它同时也暗示了牵涉到追查跟进的更强硬的态度。术语“询问”可以被解释为更温和的态度，仅仅是问问而不一定要追查跟进。筛查中关键的一点就是它仅仅是开始的一步，而不是结束，因此这里使用的语言需要被所有牵涉到的专业人员理解。大多数英国医疗专业组织在鉴别和应对医疗环境中的家庭暴力方面有推荐的计划和指导方针(如 Bacchus等人引用的(121))，但他们未必推荐它作为一种例行实践，尽管事实上有可观的定性证据支持潜在的益处(119,122)。不过英国卫生部的新出版的手册推荐人们迈向例行询问这一步。

Primary health care Younger women attend antenatal services more often than other services. Although menopausal and older women also attend gynaecological services (109), PHC may, for many abused people, be the only place of contact beyond reproductive age. Abused women have a 50–70% increase in gynaecological, central nervous system, irritable bowel and stress- related problems as well as chronic pain such as headaches or back pain (110); however, injuries that may normally be considered as the most obvious indicator may not identify women who suffer long-term problems related to abuse (108, 110–114). Postmenopausal women have been shown to be exposed to abuse at similar rates to younger women, resulting in serious threats to their health (96). Evidence has shown the high burden of elder abuse in both mortality and morbidity. An important and widely cited longitudinal study by Lachs et al. (6) demonstrated the independent impact of elder abuse on increased mortality. This study stresses the important role of doctors in identifying those at risk, initiating interventions and liaising with community services, as early identification and appropriate interdisciplinary response can save lives. There is evidence that abused persons visit PHC settings more often than those who are not abused (109, 115–118). In the United Kingdom, over 90% of the population comes into contact with PHC services within five years (119). The older the person, the higher the risk of chronic diseases (1), and therefore PHC becomes a usual and natural point of contact, implying an ongoing relationship of trust. Elder abuse cannot be addressed unless it is detected. Although PHC professionals are ideally placed to identify violence and elder abuse, in the United States for example only 2% of reported cases come from doctors (120); despite efforts to improve detection, less than 10% of PHC doctors routinely screen for domestic violence during regular clinic visits (115).

Routine screening or routine enquiry? The significance of words should not be taken lightly. While the term “screening” may have a specific meaning in public health, it also implies a stronger attitude involving follow-up. The term “enquiring” may be interpreted as a softer attitude of just asking and not necessarily following up. The critical point in screening is that it is a first step, not an end in itself, and the language used needs to be understood by all professionals involved. Most health professional bodies in the United Kingdom have recommended protocols and guidelines for identifying and responding to domestic violence in health settings (as cited by Bacchus et al. (121)), but they do not necessarily recommend it as a routine practice, despite the fact that substantial qualitative evidence supports the potential benefits (119, 122). A new handbook by the United Kingdom Department of Health, however, recommends moving towards routine enquiry (123).

如果例行询问没有完全履行筛查项目的既定原则，那么把这类询问看做筛查被认为是很费解的 (107,117,119)。尽管许多研究者声称案例搜寻比例行地询问暴力问题更合适，Bradly等人(117) 却提出例行询问是一种揭除隐藏的耻辱的方法，声称案例搜寻以及有目标地询问事实上会增加耻辱感及对报复的恐惧。要精确预判一个受虐者的形象是很困难的，因为证据显示虐待波及所有年龄层与所有社会经济地位层面(122)。因此，仅仅询问有嫌疑的人，造成偏见和耻辱的风险就会增大，也就是说，如果一个人属于低社会经济地位或者少数民族群体，那么相对一个更高社会地位的人医疗护理从业者会对其产生更多的怀疑。所以，普遍例行筛查的一个重要且正当的目标就是提出并接受这个问题，同时帮助在该问题中去除耻辱的污名。

病人的接受程度如上所述，这场争论围绕着利弊问题和伦理问题展开；被证明有效的干预方法的存在或缺失，筛查测试的有效性以及专业人员和公众对于筛查的接受程度。接受程度指的是在哪种程度下那些测试设计好的对象同意接受测试以及专业人员是否同意并且事实上使用它。在以病人为中心的方法中，接受程度应该第一个被确认，并以此决定未来的研究以及实践应该如何开展。理解各年龄层的病人对透露自己和虐待相关的经历有何感觉，可以更好地指导研究的设计以及针对基层医疗护理人员的培训项目。关于女性对家庭暴力的筛查及干预的观点与态度的研究显示，大多数女性支持或者不介意被询问是否经历过暴力，尤其是当这类询问是例行的并且细致体贴的(70,117,124-137)。Howe等人 (134)也表示在医院事故与急救部门的暴力病例中，尤其是老年病人在支持医疗人员中扮演更积极的角色。如果是直接询问，那么随着病人年龄层上升，愿意透露的比例也会上升。不过很少女性还记得曾被询问过，并且医疗记录中没有显示披露的证据(117,135)。将筛查可能的负面效果最小化的机制需要建立，因为安全性是影响女性对透露受虐待问题的接受程度的最重要因素(129)。如果例行询问由一位经过良好训练的、有感情的、有同情心的、没有偏见的医疗人员在安全的环境下所作的，那么女性会更支持它(124,130,137)。

If routine enquiry does not fulfil accepted principles for screening programmes, then it is claimed to be confusing to view such enquiry as screening (107, 117, 119). Although many researchers would claim that case-finding is more appropriate than routinely asking about violence, Bradley et al. (117) propose routine enquiry as a way of uncovering a hidden stigma, claiming that case-finding and targeted questioning may in fact increase stigma and fear of retaliation. It is difficult to predict an exact profile of an abused person, as evidence shows that abuse affects all ages and all socioeconomic levels of society (122). Thus, by enquiring only under suspicion, the risk of prejudice and stigma may increase, i.e. if a person belongs to a lower socioeconomic status or minority group, then the health care practitioner may suspect more than in a person of higher social status. Therefore, an important and justified objective of universal routine screening is naming and accepting the problem as well as assisting in destigmatizing the issue.

Acceptability by patients As described above, the debate develops around the issues of benefit–harm and ethical considerations; the existence – or lack of – proved effective interventions, the validity of the screening tests and the acceptability of screening to both professionals and the public. Acceptability refers to the extent to which those for whom the test is designed agree to be tested (82) and whether professionals agree and in fact use it. In a patient-centred approach, acceptability should be the first question to check and from which further research and practice should depart. Understanding how patients, of all ages, feel about disclosing their experiences of abuse can better guide the design of research and training programmes of PHC workers. Studies on women’s perceptions of and attitudes towards screening and interventions for domestic violence have demonstrated that most women either favour or do not mind being asked whether they have experienced violence, especially if it is done routinely and sensitively (70, 117, 124–137). Howe et al. (134) also showed that at hospital accident and emergency departments, particularly older patients supported a more active role for health professionals in cases of violence. The proportion of patients who would disclose, if asked directly, increased with age. But few women recall being asked, and medical records do not show evidence of disclosure (117, 135). Mechanisms for minimizing the potential negative effects of screening need to be in place, as safety is the most important factor in women’s acceptability to disclose abuse (129). Women favour routine enquiry as long as it is conducted in a safe environment by trained, empathetic, compassionate and nonjudgemental health professionals (124, 130, 137).

许多受虐待的女性报告说她们终于能告诉某人这些事情让她们感觉如释重负。但无论女性是否接受被询问虐待问题，她们还是可能不透露虐待事件除非她们准备好这么做了(126,133,137)。因此，理解女性在能够谈论虐待之前可能需要经历的阶段，有助于增强支持例行筛查的论据。例行筛查为准备好透露虐待的受害者提供了渠道。它也增强了支持跨职业实践的论据：在一个职业极度细分的时代，全科医生、护士和其他基层医疗护理人员无法被期望能“知道一切”或者“解决所有问题”。然而，他们预计可以联络同事以及其他专家来共同思考并且更好地理解这个过程。几乎还没有研究检验过老年女性对于被询问虐待问题的接受程度。在Zink等人的一项关于老年女性医疗护理需求以及虐待关系中生活经历的研究中，报告说医疗护理提供者看见女性和他们的配偶一起出现；极少数女性有机会与提供者私人对话，同时极少数女性对在这样的情况下谈论虐待感到舒服。研究者建议提供者应当对围绕家庭暴力的世代禁忌保持敏感，并抓住细微的迹象和线索来帮助老年女性揭露虐待。他们也应当避免年龄歧视，并且在筛查老年女性的同时也关注更年轻的病人(61,70)。一个事实变得愈发清晰，那就是当老年女性被询问的时候，她们只会具体说明想获得的医疗护理以及她们能接受什么。一份在苏格兰实施的专题小组的报告(48)引用了一位老年女性的话：当你经常地去找医生，你并不是真的想寻求那些帮助，但是我认为医生忽略了这一点。你知道他们就只是没有问“你为什么总是来这里？你家里是不是出了什么问题？”那样的话，你知道，你就会在一个安全私密的不会向外泄露任何秘密的房间，告诉他一切。但是他们从没这么做，从没有这么做。

筛查的障碍人际暴力是一个重要的健康问题(61,110,113,138-141)，但是这个问题的复杂性明显创造了一大批观点和挂虑，关于由谁在什么时间如何如理这些问题。“筛查的障碍”这类标题在文献中广泛存在，大多数来源于定性研究，概括地说明了医疗护理人员在侦测和管理虐待方面遇到的困难超越了循证医学的观点范畴。女性病人描述的揭发所面临的障碍往往和医疗护理人员是一致的 (126,142)。例如，害怕伴侣的报复，这个女性面临的主要障碍之一，在医生中也会有共鸣。医疗护理从业者表达了针对病人或者/以及他们自身实施暴力的恐惧。

Many abused women report being relieved at finally being able to tell somebody. But regardless of whether women accept being asked about abuse, they will probably not disclose abuse unless they are ready to do so (126, 133, 137). Therefore, understanding the stages that women may go through before being able to talk about abuse reinforces the argument for routine screening. Routine screening provides permission for when victims are ready to disclose. It also reinforces the argument for interprofessional practice: in an age of great specialization, general practitioners, nurses and any other PHC professionals are not expected to “know it all” and “solve it all”. However, they can be expected to liaise with colleagues and other specialists so that processes can be reflected upon and better understood. Almost no studies have checked the acceptability by older women to being questioned about abuse. In a study by Zink et al. (70) on the health care needs and experiences of older women in abusive relationships, women reported being seen by their health care providers along with their spouses; few were given the time to have private conversations with the provider, and few felt comfortable talking about abuse in these situations. Researchers suggest that providers should be sensitive to the generational taboos around domestic violence and pick up on hints or clues to assist older women to disclose abuse. They should also avoid ageist assumptions and screen older women as well as younger patients (61, 70). It becomes clear that when older women are asked, they specifically say what they would expect from the health care and what is acceptable to them. A report on focus groups conducted in Scotland (48) quotes an older woman: You don’t actually ask for help like that but I think the doctors miss it, when you go constantly to the doctors. And you know they just don’t ask the questions “Why are you always in here? Is there something wrong at home?” And you would tell that, you know, in a safe, private room where you know it won’t go any further. But they never did – they never did.

Barriers to screening Interpersonal violence is an important health problem (61, 110, 113, 138-141), but the complexity of the issues clearly creates a range of views, and anxieties, as to how to tackle them, by whom and when. The generic title “barriers to screening” found extensively in the literature, mostly through qualitative studies, encapsulates the difficulties of health care professionals in the detection and management of abuse beyond the medical evidence-based point of view. Often, the barriers to disclosure described by women patients parallel those of health care staff (126, 142). For example, fear of retaliation by the partner, one of the main barriers among women, will be shared by practitioners. Health care practitioners express fear of violence either or both against the patient and/or themselves.

探索基层医疗护理从业者对于家庭暴力的态度的研究揭示了一些专业人员认为阻碍他们“舒适地”干预暴力受害者的障碍，比如“害怕被攻击”、“无力感”、“害怕被报复”、以及“时间的压迫”。“开启潘多拉的盒子”这个比喻重复出现(115,128,143-149)。现在在老年病人中侦测虐待更增加了辨别虐待、年龄相关身体异常以及记忆混乱的困难和复杂性(5,150,151)。缺乏有效的干预手段、强制报告以及缺少适当的知识也是经常被提到的障碍。在一些情况下，护士和医疗助理似乎比医生在询问虐待问题方面感到更舒适，但是他们都感到缺乏相关问题的教育，并且尤其缺乏和基层医疗护理环境外的其他专家的转交联系(146)。 Roberts(152)引用了护理(care)的词典定义，“从喜爱与关心，到小心，有责任感，对想法的抑制，焦虑和悲伤”。基层医疗护理人员会在工作中感受到这一切，因此他们需要机构与社会的认可和支持来有效地完成困难的任务。近距离地接触痛苦以及死亡的工作会因工作压力而导致各种焦虑不安。各机构使用了许多预防机制来控制焦虑而不是承认这是工作的正常的一部分(153)。护理老年人带来了更多的压力。就好比社会如何排斥老年人，面向老年人的工作也被认为在医疗护理专业领域处在低下的地位。工作人员的的努力应当被认可，他们的感受应当被倾听，这样才能改善所有相关的人的生活质量(32,152)。仅仅推荐老年人虐待或者家庭暴力例行侦测工具的介绍是不够的。为了让专业人员能有效地使用工具，他们需要被培训以了解这个问题以及它的迹象、症状和后果。此外，当虐待和忽视被侦测到的时候他们需要做好干预的准备。不过最首要的，他们需要有自信来克服一切阻止他们侦测和干预的障碍。老年人与家庭虐待是复杂的问题并且总是需要和其他人“对抗”，更加确定的医疗护理问题，比如心血管疾病、癌症和急性炎症护理，使得医疗护理提供者在处理一个社会慢性问题的同时还要完成医疗从而增加了困难。然而，正如之前提到的，一些慢性症状，包括精神健康问题 (61,110)，会是由长期的虐待关系所导致的，因此增加了医疗诊断的数量。有人提出与其把暴力视作一种疾病，将暴力看作是可能导致一长串疾病的风险因素更有助于基层医疗护理从业者，同理烟草和酒也是如此(107,128,154)。这种视角有助于基层医疗护理人员理解筛查的相关作用，也就是它可以帮助他们领会他们的病人出现并/或反复出现的症状，而其他情况下这些内容不会被提及。他们可以在所有例行的病史采集过程中以及伴随吸烟和酗酒问题询问关于虐待的问题。事实上，虐待可能是一个导致过量吸烟和/或酗酒的因素(110)，增加了建立联系的相关性。然而，这种方法不能解决作为基础的困难和障碍。

Studies exploring PHC practitioners’ attitudes to domestic violence reveal several barriers that staff perceive as preventing them from “comfortably” intervening with violence victims, such as “fear of offending”, “powerlessness”, “fear of retaliation” and “tyranny of time”. The image of “opening Pandora’s box” appears repeatedly (115, 128, 143–149). Detecting abuse among older patients presents added complications and complexities in distinguishing between abuse, ageing-related physical conditions and memory impairments (5, 150, 151). Lack of effective interventions, mandatory reporting and lack of appropriate knowledge are also commonly mentioned barriers. In some cases, nurses and medical assistants seem to feel more comfortable than doctors in enquiring about abuse, but they share the sense of lack of education on the issues and, especially, lack of referral contacts with other professions outside the PHC setting (146). Roberts (152) cites dictionary definitions of care as “ranging from affection and solicitude, to caution, responsibility, oppression of the mind, anxiety and grief”. PHC staff can feel all these ways at work and they need institutional and social recognition and support to carry out difficult tasks effectively. Working closely with suffering and death can lead to various anxieties connected with the burden of the work. Many defence mechanisms are used by organizations to control anxieties instead of acknowledging them as a normal part of work (153). Caring for older people brings with it particular stresses. In parallel with the way in which older people are excluded from society, working with them is considered to be low status among the health care professions. The efforts of staff need to be recognized and their feelings heard in order to improve the quality of life of all involved (32, 152). Recommending the introduction of elder abuse or domestic violence routine detection tools by itself will not be enough. For professionals to be able to use the tools effectively, they need to be trained to be aware of the problem and its signs, symptoms and consequences. In addition, they need to be prepared to intervene when a case of abuse or neglect is detected. Above all, they need the confidence to overcome barriers that prevent detection and intervention. Elder and domestic abuse are complex issues and will always be “competing” with other, more established health care issues, such as cardiovascular diseases, cancer and acute care, adding to the difficulty for health care providers in dealing with a social chronic problem while medicalizing it. However, as already mentioned, several chronic conditions, including mental health problems (61, 110) may result from long- lasting abusive relationships with a consequent increase in medical consultations. It has been proposed that instead of viewing violence as a disease, it may help PHC practitioners to see violence as a risk factor for a long list of diseases, in the same way that tobacco and alcohol are viewed (107, 128, 154). This approach may help PHC workers understand the relevance of screening, as it would assist them in comprehending the emerging and/or recurring conditions of their patients that would otherwise have remained unspoken. They could enquire about abuse in all routine medical history-taking along with questions on smoking and excessive alcohol consumption. In fact, abuse may be a factor in itself for excessive smoking and/or drinking (110), increasing the relevance of making the connections. However, this approach will not solve the underlying difficulties and barriers. 48

对家庭暴力的医学化常常被指责为一种缄默(118,145)，同时声称在医疗护理环境中的医学措辞和制度对许多困难负有责任。当使用术语“病人中的传播率”之时，医学疏远了自己和社会框架以及病人的经历之间的距离。有人声称医学模型所使用的技术“将社会认可的统治与控制的制度在机构中制度化，这些技术模仿了虐待的动态”(145)。在这种模型下训练出来的临床医生会感到难以提供受虐病人最需要的帮助以及超越伤口本身而看到导致它们的真正原因(124,145,155)。这些任务对于提问的医疗人员来说并不容易。希望“修复”状况并完成良好结果的期望，伴随着它们的无力，使得他们感到无助、精疲力尽并且专业上的无能(107,128,148,149,156)。制度以及结构性障碍妨碍了医疗护理人员的努力，比如管理与组织变动、缺乏支持以及缺少适当的交流。在英国社区护理协会(157)的一项调查中，仅有26%的应答者报告他们的雇主在处理老年人虐待方面提供了职员互助的计划，甚至更少(19%)的人报告说他们在处理家庭暴力方面有类似计划。医疗护理人员认为他们自己也受到了这个系统的虐待；尤其当面对老年人的工作被认为是“二流的”，工资更低并且比其他领域配备相对更缺乏能力的职工(7)。医疗护理人员处理虐待的困难还可能源于过去的个人或者职业经历中或曾动用暴力而感到的强有力的感觉。可以假定听取虐待经历让人有强烈的感受是正常的反应；问题是不去承认这种虐待

经历带来的痛苦的感觉和其影响(145,149,158)。既然知道虐待是很普遍的，那么假设医疗护理人员中有一大部分也处于其中——无论是作为施虐者还是受害者——是符合逻辑的。他们无法逃离社会与文化习俗比如关于性别歧视或者他们自己的年龄歧视态度与行为；他们自身的偏见可能会对鉴别虐待情形以及提供合适的帮助造成困难。除非基层医疗护理体系和整个社会承认个人感受和职工经历，否则想要期望所有医疗护理职工按照计划行动是很困难的。

The medicalization of domestic violence is often blamed for the silence (118, 145), with claims that medical language and hierarchies in health care settings are responsible for many of the difficulties. While talking in terms of “prevalence in patients”, medicine distances itself from the social framework and the experiences of patients. It has been claimed that techniques used by the medical model “institutionalise socially sanctioned hierarchies of domination and control, techniques that mimic the dynamics of abuse and battering” (145). Clinicians trained within that model would find it difficult to provide the support that abused patients most need and look beyond the injury itself to take into consideration what may have really been the cause (124, 145, 155). The task is not an easy one for the health professionals who do ask. Expectations to “fix” situations and achieve good outcomes, and their inability to do so, create feelings of helplessness, burnout and professional incompetence (107, 128, 148, 149, 156). Institutional and structural barriers hinder the efforts of health care staff, such as management and organizational changes, lack of support and lack of proper communication. Only 26% of respondents to a survey by the United Kingdom Community and District Nursing Association (157) reported receiving any staff-support scheme by their employer when dealing with elder abuse, and even fewer (19%) reported having a scheme for those dealing with domestic violence. Health care professionals also see themselves as abused by the system; especially working with older persons is considered “second class”, with lower wages and less qualified staff than in other areas (7). Health care professionals’ difficulties in tackling abuse may also be due to possible past personal or professional experiences with violence resulting in powerful feelings. It can be assumed that it is a normal reaction to have strong feelings when listening to experiences of abuse; the problem is the failure to acknowledge the feelings and their impact (145, 149, 158). Knowing that abuse is prevalent, it is logical to suppose that a large percentage of health care professionals are part of the statistics, either as abusers or as victims of abuse. They do not escape from social and cultural norms regarding sexism or their own ageist attitudes and behaviours; their own biases may be an obstacle in identifying abusive situations and provide appropriate assistance. Unless the PHC system and society as a whole acknowledge personal feelings and staff experiences, it will be difficult to expect all health care staff to behave according to protocols.

信任医疗护理从业者与病人之间的信任关系会对打破虐待循环造成很大影响。许多女性表达了她们对于基层医疗护理人员的不信任。Rodriguez、Szkupinski和Bauer(124)用一位研究参与者的话描述了一种“默认的同意”或者“沉默的代码”。这表现为三种方式：病人不寻求医疗护理，病人不透露信息以及医疗护理从业者不作询问。在另一个研究中，一些确实揭露了家庭暴力的女性认为卫生访视员比全科医生以及事故急救人员要更具同情心并且一般来说更有帮助(121)。需要注意的是，除了卫生访视员，全科医生和护士也参与家庭访问，尤其在与身体虚弱的老年人来往时 (34,95)。因此，是对生活环境的了解以及个人间的持续关系激发了信任，而不是职业本身。从业者的性别似乎并不是一个重要的因素或者障碍(115,126)。重要的是被关心而不是被评判、被倾听而不是被调查的感受。在医疗护理从业者的行为中可以辨别出五方面对建立与病人的信任关系以及有助于揭露事实的重要因素：开放的交流、专业素养、友好的业务风格、关心的态度以及感情上的平等(159)。一个虐待受害者会得到巨大的安慰，如果一位医疗护理人员说出了病人正处于的情绪状态或者帮助病人表达这种情绪。这些情绪常常可以通过病人或者施虐者的行为线索辨别出来，这些线索有时候就像是在“呼喊救命”(160)。医疗护理可能比以前变得更加复杂，但是这份职业的核心依然是基本的人类关系。如 Schatter(161)所言，“简单就是美”。往往，医疗护理人员为一个没有诊断出来的情况浪费时间和金钱安排一系列的测试，而事实上，一个好的诊断可能只需要倾听并信任病人所表达的词句、表情和暗示。让经验有效地帮助受虐待的女性前行(137,162-164)。和老年人交流也需要更多的耐心以及理解提出一个禁忌问题可能面临的世代与文化障碍。在和虚弱的老人交谈时，无论他/她是否遭受认知损伤，一个关键要注意的地方就是确保看护者没有控制这次交谈，可以通过同时和病人以及看护者作单独面谈的方法(32,165,166)。保密这个重要概念在现在的文献中常常作为一个鉴别并/或揭露虐待的主要障碍并影响着信任关系(159)。在不同的场合下这个概念往往被无差别地使用。这使得它的意义以及在什么时候如何才需要遵循保密条例变得令人困惑。保密可以和女性所处的阶段相联系，建立关系以使得女性可以揭露虐待并做出合适的行动(137)。

Trust A trusting relationship between the health care practitioner and the patient can make all the difference in breaking the cycle of abuse. Many women express their lack of trust in PHC professionals. Rodriguez, Szkupinski & Bauer (124) describe an “unspoken agreement” or a “code of silence” in the words of a participant of the study. This is represented in three ways: the patient does not seek health care, the patient does not disclose and the health care practitioner does not ask. In another study, some women who had actually disclosed domestic violence regarded health visitors as more sympathetic and in general more helpful than general practitioners and accident and emergency staff (121). It should be noted that, in addition to health visitors, general practitioners and nurses perform home visits, especially when dealing with frail older people (34, 95). Thus, it is the knowledge of the living environment and the personal ongoing relationship that inspires trust, and not the profession itself. The sex of the practitioner does not seem to be an important factor or barrier (115, 126). It is the feeling of being cared for, not judged, not looked over but listened to, that is important. Five dimensions can be identified in health care practitioner behaviour that are essential for the building of trust with their patients and that contribute to disclosure: open communication, professional competency, a friendly practice style, a caring attitude and emotional equality (159). A victim of abuse can experience dramatic relief when a health care professional verbally recognizes an emotional state the patient is in or helps the patient express an emotion. These emotions can often be recognized from clues in the patient’s or abuser’s behaviour, these clues sometimes being like “cries for help” (160). Health care may be more sophisticated than ever before, but at the core of the profession is the basic human relationship. “Simple is beautiful” as Schattner (161) puts it. Often, health care professionals waste time and money ordering a battery of tests for an undiagnosed condition when, in fact, a good diagnosis could have been made had there been an attempt to listen to and trust the words, the expressions and the hints given by the patient. Validating the experience, helps the abused woman move forward (137, 162–164). Communicating with older persons may also require more patience and understanding of the possible generational and cultural barriers for bringing up a taboo issue. A crucial concern when communicating with a frail older person, regardless of whether that person is suffering from cognitive impairment or not, is to make sure that the caregiver does not dominate the conversation, by holding separate interviews with both the patient and the caregiver (32, 165, 166). Confidentiality is an important concept that is much present in the literature as a major barrier for identification and/or disclosure of abuse and impacting the relationship of trust (159). The concept is often used indiscriminately while it refers to different situations. This creates confusion as to what is really meant by it, and when and how confidentiality rules need to be followed. Confidentiality can be related to the stage the woman is in, building the relationship so that the woman can disclose and also take appropriate action (137).

然而，保密需要首先从安全的角度来进行分析；过程和步骤需要在一开始就被阐明；因为医疗护理实践不是在真空环境下实施；保密的具体意义是什么以及它的限制是哪些。为了提供最佳的护理需要跨职业的咨询，这通常超过了一个从业者个体的能力范围。保密这时候是在一个团队层面起作用。当还没有采取必要措施让病人远离施虐者时，无异于事实上和虐待者“共谋”(167)，这时保密对于保护病人安全是必要的，需要带有良好的判断能力、敏感性以及小心谨慎来进行观察。医疗护理提供者与病人之间开放、诚实的交流，以及互相的信任和共同决策，有助于授权的过程以及问题更好的解决。

不同护理人员之间的交流如上所述的阻碍基层医疗护理人员和病人之间信任关系形成的障碍，和阻碍跨岗位的优秀协作的障碍相似(142)。基层护理的性质，牵涉到许多的组织和专业壁垒，可能对许多的从业者提出了挑战。然而，它也同时提供了机遇，通过有效的跨专业合作发展针对老年人虐待和暴力的良好的实践。尽管将暴力和老年人虐待识别为一个公共医疗问题是发展良好实践的重要一步，但是过度医学化、只从身体损伤或临床角度看待暴力的危险趋势正在成为事实(118)。虐待通常和其他社会问题共存，而基层医疗护理人员可能没有准备或者没有时间来处理这些问题。理解到没人能期望医疗护理人员解决所有问题，对于增进不同专业间的交流和合作是重要的一步，包括在基层医疗护理环境内部的合作，以及和社会服务部门、警察、法律服务、志愿者组织、女性与老年人利益组织。

D’Avolio等人(116)描述了一些医疗护理人员交流筛查和虐待的极端方式。在一些情况下，工作人员会采取一种“不要问，不要说”的态度来为避免筛查作借口；而在另一些情况下，工作人员会热情地参与，普遍地进行例行筛查，但是过于保护他们的病人以至于就算鉴别出了家庭暴力案件也不联系其他同事。这些行为和受虐待女性之间、以及/或者她们亲近的人和看护者之间的关系很相似，并且应当可以通过一个定期的小组实践反思活动得到讨论、承认以及处理。在那些被认为“更关心人”的工作成员心中可能充满了被孤立和边缘化的感受，使他们变得不受欢迎(116)。一般来说，被孤立的感觉不止会出现在特定工作场所，也会出现在更广泛的社会环境下。专业人员之间的竞争在某个团队中或者不同专业间出现是很平常的事情。成员会对最初的团队显得忠诚并倾向于和其他团队的人竞争。对两位或多位成员的适当管理对于出色完成任务以及有效合作实践是非常关键的(168)。

However, confidentiality needs to be analysed above all from a safety point of view; processes and procedures need to be clarified from the start; that health care practice is not performed in a vacuum; what exactly confidentiality means and what are its limitations. Interprofessional consultation is done in order to provide optimal care, which often is beyond the ability of the individual practitioner. Confidentiality then is kept within the context of a team. Good judgement, sensitivity and caution are needed to discern when confidentiality is essential to keep the patient safe and when it is in fact “colluding” (167) with the offender by not taking the necessary action to distance the patient from the abuser. Open, honest communication between the health care provider and the patient, involving mutual trust and shared decision-making, contributes to the empowerment process and better resolution of the issue.

Communication between different care professionals The barriers that prevent a trusting relationship between a PHC practitioner and a patient, as described above, parallel the barriers that prevent good work across disciplines (142). The nature of primary care, involving a number of organizational and professional boundaries, may provide a challenge for many practitioners. However, it also provides an opportunity to develop good practice on elder abuse and violence through sound interprofessional partnerships. Although the recognition of violence and elder abuse as a public health issue is an important step for developing good practice, the dangers of overmedicalization, looking at violence from only an injury or clinical point of view, become evident (118). Abuse often coexists with other social problems, which PHC may not be equipped or may not have time to deal with. Understanding that nobody expects health care settings to fix all the problems is an important step to improving communication and collaboration among different professions, both within the PHC and with social services, the police, legal services, voluntary organizations, and women’s and older people’s interest groups. D’Avolio et al. (116) describe some extremes in the way health care staff communicate about screening for abuse. In some cases, staff would adopt a “don’t ask, don’t tell” attitude as a justification to avoid screening, while in others staff would be so passionately committed that they would screen universally and routinely but would remain so protective of their patients, to the point of not involving their colleagues in cases of identified domestic violence. These behaviours clearly parallel the relationship between abused women, and/or people close to them, with care providers, and could be discussed, acknowledged and dealt with in a regular team reflective practice sessions. Feelings of isolation and marginalization may also abound among members of staff who may be perceived as “more caring” than others, becoming unpopular (116). The feelings of isolation can be present at a specific workplace but also in the wider context of society in general. Competition among professionals is common within a certain group and across the boundaries of professions. Members feel loyal to their original group and tend to be competitive with others. Appropriate managing of dual or multiple memberships for the good of the task and effective collaborative practice is critical (168).

报告制度被广泛争论并且被医生们认为是询问和揭露事实的障碍。医生以及病人并不知道报告会带他们走向哪里，并且不想和各种官方文件以及警察打交道(19,128)。义务报告是另一个有争议的问题，并且在美国大多数州对于老年人虐待问题这是强制要求的。有人提出与其将报告看作是一种调查手段，不如将其看作一种试图决定哪些可行的服务会对于受虐老人有帮助的制度(92)。有一些证据显示，通过报告给政府当局，给虐待者传递了一个强烈的信号，而结果家庭暴力减少了 (169)。持续保持支持受害者以及追究措施可能会产生一个长期的效果。只有通过不同专业间的对话，才能阐明报告需要什么以及如何完成适当的实施及服从。报告、保密及信息共享是关键的问题，需要建立专业小组间清晰的行动守则。信息共享非常有助于虐待案件的识别和鉴别，使得它可以阻止虐待行为的发生并挽救生命，这需要良好的专业间交流(167)。部分关于信息共享的争论围绕着如何平衡个人与公共利益、个人或团体的人权与公共卫生和安全(170)。有必要注意这里的不同的人权是相互关联的，它们很难被区分开来单独看待(171)；因此当善意的医疗护理人员正在保护一位病人的隐私权时，与此同时也可能正在危害一位病人获得安全的权利。在这种背景下，公共卫生和人权领域为同样的保护人们生命权利不受虐待侵犯的目标而协作。不同的专业处于各自特定的语言以及行动守则的训练下，这有时候似乎使得要形成纽带变得不可能。在如今的信息科技时代，有某些技术手段可以增强信息共享和交流，在采取重要的保护预防措施的前提下(167,170)。需要的是根据个体当事人和社会的需要进行改编的意愿，以使得基层医疗护理可以更好地帮助虐待受害者并阻止将发生的虐待。需要适当的管理而不只是协调来促进成功的合作(168)。基层医疗护理环境如何处理通过对虐待的例行筛查得到的信息，以及如何管理跨专业的应对，会产生重要影响。正式的转交协议，比如那些在美国应用了多年的协议，使得跨领域交流成为可能。这种经验促成了多领域团队的形成，涉及老年人虐待的各个方面，从筛查、鉴别、评估到干预以及跟进 (58,172,173)。这种做法的强有力之处在于它们注意到每个专业领域的限制，将不同观点一起加以考虑以充分地评估有嫌疑或者已确认的虐待情境，因此也分担了责任。一些团队已经成功地打破了之前阻碍有效的互相交流的障碍。

Reporting is much debated and is mentioned by doctors as a barrier to enquiry and disclosure. Doctors – and patients – do not know where the reporting will take them, and do not want to work through bureaucratic papers and deal with the police (19, 128). Mandatory reporting is another issue of controversy and is in force, for elder abuse, in most states in the United States. It has been proposed that instead of considering the report as an investigation, it can be framed as the attempt to determine what services are available that might benefit the abused older person (92). There is some evidence to suggest that by reporting to the authorities, a strong signal is sent to the abuser, and as a consequence, domestic violence declines (169). Maintaining support to the victim and follow-up may have a lasting effect. Clarity as to what reporting entails and appropriate implementation and compliance will only be achieved only through a dialogue between the professions. Reporting, confidentiality and information-sharing are crucial issues that necessitate a clear code of conduct among professional teams. Sharing information is particularly relevant to the recognition and identification of cases of abuse when sharing can prevent acts of abuse and save lives, reflecting the need for good interprofessional communication (167). Part of the debate on sharing information revolves around the balance between individual and public interests, between a person’s or group’s human rights and public health and safety (170). It is important to note here that different human rights are interrelated, and they can very rarely be seen in isolation (171); so while well-intentioned health professionals may be protecting a patient’s right to privacy, at the same time they may be violating a patient’s right to safety and security. In this context, public health and human-rights fields work together towards the same goal of protecting people’s right to life, free of abuse. Different professions have been trained within specific languages, codes of conduct and behaviours, which sometimes seem impossible to bridge. In these times of information technology, there are technical ways to improve information-sharing and communication, while taking important safeguarding precautions (167, 170). What is needed is the will to adapt to the needs of both individual clients and society, so that PHC can better help victims of abuse and prevent future abuse. Appropriate management and not just coordination is needed for successful collaboration (168). What a PHC setting does with the information that may be collected through routine screening for abuse, and how the interprofessional response is managed, can make a difference. Formal referral protocols, such as those in use in the United States for many years, enable interdisciplinary interaction. The experience has led to the formation of multidisciplinary teams for all aspects of elder abuse, from screening, identification and assessment through to interventions and follow-up (58, 172, 173). The strength is that they acknowledge the limitations of each discipline while taking into consideration the different points of view in order to assess fully the situation of suspected or confirmed abuse, therefore sharing the responsibility. Some teams have succeeded in breaking the barriers that had previously prevented helpful interactions.

干预尽管对虐待的及早鉴别很重要，例行筛查的效用最终还是取决于有效的干预。干预不是意味着修复问题，而是描述并接受它以及承认基层医疗护理层面的局限性，将它转交并引导至跨专业的合作。应用于理解虐待的本质和原因的同一个生态学模型，将有助于计划合适的干预方案，综合考虑每个个体、人际关系、社区以及社会层面。当虐待被鉴别出的时候，最优先的是在尊重老年人自主权的基础上确保老年人的安全(31,92)。在调和自主权和安全性的过程中可能会产生矛盾，这也可能导致老年人拒绝干预，因此进一步需要从业者更强的交流能力以及建立与病人和同事间的信任关系。通过采用以社区为中心的跨领域协作方式来预防和管理老年人虐待问题受到越来越多的推荐强调(1,3,14,15,29,79,80,123,174)。然而，为了克服各种阻碍成功的合作关系以及跨领域实践的障碍，理解组织如何运作、自觉的和无意的程序以及和/为他人工作会牵涉的各种挂虑是非常重要的。了解可行的服务、注意到每种服务的优点和缺点并且同时保持有效的跨领域实践，有助于提高对老年人虐待的了解并有信心寻找到有效解决的途径。

培训尽管缺少对筛查的支持，北美和欧洲筛查委员会还是号召卫生服务部门推广相关的教育和培训，以了解暴力对女性健康造成的严重影响并鉴别和支持受虐女性。专业培训具有增进从业者了解程度、舒适度和鉴别能力的潜力；然而，如果不能在更广泛的社会文化环境下定位虐待，没有允许进一步教育、监管和支持的社会结构变化，很难有什么真正意义上的改进。有资料表明筛查计划的介绍提高了侦测率(106,175)。然而，这种努力很难维持 (21,107,175-177)。因此，可能有人争辩说介绍例行筛查和转诊计划并不值得努力。事实可能刚好相反，这巩固了对进一步培训和监管的论辩。为了能成功地实施并维持例行询问和干预，工作人员需要持续的支持和可用资源的更新。D’Avolio等人(116)报告称，当它们为工作人员提供了更新的课程和个人交流后，筛查率进一步上升。

Interventions While early identification of abuse is essential, the efficacy of routine screening ultimately will depend on effective interventions. Intervention does not mean fixing the problem but rather naming and accepting it and the limitations of the PHC level, leading to referral and interprofessional cooperation. The same ecological model that is applied to understanding the nature and causes of abuse will assist when planning appropriate interventions that take into account each of the individual, relationship, community and society levels. When abuse is identified, the highest priority is to ensure the safety of the older person while respecting the person’s autonomy (31, 92). The conflict that may arise in accommodating both autonomy and safety, as it may be the case that the older person refuses intervention, reinforces the need for greater communication skills of practitioners and the building of trust with their patients and with colleagues. More emphasis on elder-abuse prevention and management through the adoption of interdisciplinary community-based approaches is increasingly recommended (1, 3, 14, 15, 29, 79, 80, 123, 174). However, in order to overcome multiple barriers that prevent successful partnerships and interdisciplinary practice, it is crucial to understand how organizations work and the conscious and unconscious processes and anxieties involved when working with and for people. Knowledge of available services, acknowledging the strengths and limitation of each service while maintaining effective interprofessional practice, contributes to raising awareness about elder abuse and developing the confidence and mechanisms for addressing it effectively.

Training Despite the lack of recommendations to screen, screening committees in North America and Europe call on health services to promote education and training, to be aware of the serious impact of violence on women’s health and to identify and support abused women. Professional training has the potential of increasing the knowledge, levels of comfort and identification among practitioners; however, without situating abuse within the broader sociocultural context and without structural changes that allow for continuing education, supervision and support, little change will occur. It has been shown that the introduction of screening protocols improves rates of detection (106, 175). However, efforts have been difficult to sustain (21, 107, 175–177). Therefore, it might be argued that the introduction of routine screening and referral protocols is not worth the effort. In fact, the opposite may be the case, strengthening the argument for continuing training and supervision. In order to successfully implement, and sustain, routine questioning and intervention, staff need continuous support and updating of the available resources. D’Avolio et al. (116) report that when they provide refresher courses and interact personally with staff, the rates of screening go up.

大多数文献强调了对家庭暴力以及老年人虐待问题培训的需求，这些文献来自护士、研究者、医生或者委员会(7,15,24,94,141,148,156,157,178)。重要的问题是开发并实施有效并持续的培训，针对于从本科生到各种终身职业，以对各层面的实践活动造成影响。许多描述老年人虐待的迹象和症状的作品被出版，但是影响微乎其微。医疗和社会服务人员需要更多的技巧和知识来有效地处理老年人虐待，仅仅简单地分发打印材料是没用的，设计合适的有特定对象的教育研讨会来补充知识缺陷才可以提高实践能力(179)。同时有证据表明通过关于亲密伴侣暴力的讲座所作的有限的培训并不能对筛查行为有什么影响，不过培训部分加上提供筛查问题以及转诊计划显得更加有效 (147)。教育和培训远远不只是复习一下识别虐待的迹象和症状；同时通过学习和实践对复杂机理有更深的反思和理解才是极具价值的。聚焦于消除基层医疗护理人员对家庭暴力程度或方面的误解的持续培训可以增加筛查率并明显地提高实践水平(148,175,180)。有人提出培训应当包含反思护士自身经历和态度的机会，如果有必要还可以提供个人咨询(158,181)。一个连接定性研究以及教育工具的项目由西雅图的Nicolaidis提出(163,164)。一份特写了受虐女性叙述她们对医患关系的观点并清楚地对摄像机说出了她们希望这种关系如何发展的录像被制作了出来。这种类型的培训可能有助于打破讲座的过于正式性，并作为医生们“听和看”的素材，然后和他们的同事共同讨论和反思自己的相关职业经历。这个项目的另一个价值在于其参与的性质。在该定性研究中被访问的女性同时也参与脚本的写作以及录像的剪辑。上面提到过，有时候护士在询问虐待时会比医生感到更舒适，而病人有时候也会感到更舒适如果和护士或者医生或者助手在一起。这点在理解跨专业培训的作用上至关重要，这也会提高团队配合。在组织内以及跨机构的团队训练都需要被考虑。Pritchard(156)强调了培训计划有合法性、志愿性以及独立性的重要之处。跨专业培训会议是一个阐明行为守则、程序、语言以及其他实践问题的好机会。它们也可以促进个人联系，有助于减少不同职业间以及专业人员和当事人之间存在的偏见与成见。根据生态学模型，处理虐待的障碍存在于个人、人际间、社区以及社会层面。因此，为了克服这些障碍的干预措施也同时需要在所有层面实施。教育和培训项目可以通过寻找整个社会的合作伙伴得以发展。和媒体以及娱乐行业间的良好关系，举例来说，可以为大规模媒体宣传以及教育活动创造好机会，触及到受虐者、施虐者、教师、服务和护理提供者以及政策制订者。

Most literature highlights the need for training on family violence and elder abuse, as reported either by nurses, researchers, doctors or committees (7, 15, 24, 94, 141, 148, 156, 157, 178). The important issue is to develop and implement effective and continuing training from undergraduate studies and throughout a lifetime career that can have an impact at all levels of practice. Many articles describing signs and symptoms of elder abuse have been published, but they have little if any impact. Health and social services staff need greater skills and knowledge in order to manage elder abuse effectively, and suitably targeted educational seminars designed to fill knowledge gaps can improve practice, while simply distributing printed materials is ineffective (179). It has also been proven that limited training through lectures about intimate partner violence does not have a significant impact on screening behaviours, whereas training sessions plus the provision of screening questions and referrals protocols appears to be more effective (147). Education and training are much more than just reviewing signs and symptoms to recognize abuse; a deeper and reflective understanding of the complex mechanisms involved in both learning and practice are invaluable. Continuing training with a focus on dissipating PHC staff’s misconceptions about the extent and aspects of domestic violence may increase screening rates and clearly improve practice (148, 175, 180). It has been proposed that training should include the opportunity to reflect on the nurse’s own experiences and attitudes and offer personal counselling if needed (158, 181). A project coupling qualitative research with educational tools was carried out by Nicolaidis in Seattle (163, 164). A video was produced featuring women who had experienced abuse talking about their views on the doctor–patient relationship and clearly saying to the camera how they would have liked the relationship to develop. This kind of training may be useful to break the formality of lectures and can be used as a basis for doctors to “listen and look” and then discuss and reflect with their peers on their own professional experiences. One added value of this project is its participatory nature. The women who were interviewed for the qualitative study also participated in the writing of the script and editing of the video. As mentioned, nurses sometimes may feel more comfortable enquiring about abuse than doctors and patients sometimes may feel more comfortable with the nurse, or the doctor or an assistant. This point is crucial in understanding the relevance of interprofessional training, which in turn would improve team practice. Both training of teams within an organization and interagency training need to be considered. Pritchard (156) stresses the importance of involving statutory, voluntary and independent sectors in training plans. Interprofessional training sessions are a good opportunity to clarify codes of conduct, procedures, language and other practice issues. They also promote personal connections, which contribute to reducing prejudice and stereotypes that exist among different professions and between professionals and clients. According to the ecological model, the barriers to deal with abuse are at the personal, interpersonal, community and societal level. Therefore, interventions for overcoming the barriers also need to be implemented at all levels. Education and training programmes can be developed with partners across society. A good relationship with the media and the entertainment industries, for example, provide good opportunities for mass media awareness and educational campaigns that reach abused people, abusers, teachers, service and care providers and policy-makers. 60

4. 结论以及对行动的启示概括性结论老年人虐待是一种对人权的侵犯，影响到老年人生活的方方面面。基层医疗护理在鉴别、处理和预防它的发生上扮演着重要角色，通过提高和病人间的信任水平、实施例行筛查以及有效地与社会中其他服务共同合作。除了必要的科学上的和法律上的责任，也需要在人权框架下的人道主义的医疗护理方法。这份综述试图将老年人虐待置于生态学模型的理论框架内，将个人放在他/她生活的环境下。研究、教育和实践分别聚焦于生态学模型的各个层面，考虑了它的所有层面，或许可以简化处理这个复杂问题的难度。基层医疗护理人员发现了影响识别老年人虐待的多个障碍。这些障碍存在于生态学模型的各个层面。在社会层面，广泛传播的年龄歧视的态度渗透到生活的各个方面。这转化为了社会中对老年人的虐待和歧视，包括在医疗护理体系中。老年人虐待的性别方面被社会上广泛传播的性别歧视所掩盖。性别歧视和年龄歧视合起来将老年女性置于最容易受到伤害的处境。老年人并不是一个同质的群体。对老年人虐待的研究需要识别个人的生命历程、家庭关系背景以及可能的长期受虐经历。老年人的脆弱以及依赖性状况，作为一个导致虐待的因素，应当在包括受虐者与施虐者的关系以及施虐者的特征在内的整体环境下被理解。鉴于虐待有许多的类型，老年人虐待并不只是一个单一的问题而是一个无数问题的集合，需要无数的应对方式。增强信任和交流是有效处理虐待问题的核心，这个过程遍及所有关系：在受害者和施虐者之间，在受害者和医疗护理从业者之间，在医疗护理内外不同职业间以及在政府部门或者政策层面和公众之间。

4. Conclusions and implications for action General conclusions Elder abuse is a violation of human rights that affects every aspect of the older personâ&#x20AC;&#x2122;s life. PHC has an important role in identifying, managing and preventing its occurrence by increasing the level of trust with patients, implementing routing screening practice and effectively working with other services in the community. Beyond the required scientific and legal responsibilities, a humanistic approach within a human-rights framework to health care is needed. This review has attempted to place elder abuse within the theoretical framework of the ecological model, placing the person within the contexts in which s/he lives. Research, education and practice focused at each level of the ecological model, taking into account all of its levels, may simplify the task of tackling the complex issues. Multiple barriers have been identified that have an impact on the recognition of elder abuse by PHC workers. These barriers exist at all levels of the ecological model. At the societal level, widespread ageist attitudes permeate all aspects of life. This is translated into abuse and discrimination against older persons in society, including in health care settings. Gender aspects of elder abuse are obscured by widespread societal sexist attitudes. Sexism and ageism together place older women as the most vulnerable. Older people are not a homogeneous group. The study of elder abuse needs to recognise the life course experiences of a person, the context of family relationships and possible life-long experiences of abuse. Situations of frailty and dependence of the older person, while a contributing factor to abuse, should be understood within the overall context of the relationship between the abused and the abuser along with the characteristics of the abuser. As there are multiple types of abuse, elder abuse is not just one single problem but a myriad of problems requiring a myriad of responses. Improving trust and communication are central for dealing effectively with abuse and parallel processes are observed throughout all relationships: between the victim and the abuser, between the victim and health care practitioners, between different professions both within health care and outside, and also between governments or policy levels and the public.

这篇综述自始至终都提到，使用的语言和定义缺乏一致性是有效实践的一块绊脚石。不去混淆哲学论述和日常实践用语是至关重要的：尽管定义综合了作为研究和实践的基础的中心主题而因此很重要，不过同时帮助目前的受害者的行动更为紧急。除了如何定义老年人虐待缺乏一致以外，一个关键的例子是讨论应该应用筛查还是询问。医学模型的至高无上，以及它所暗示的客观的科学的含义，正在面临挑战。语言不能被任何一个学科所垄断：它是在社会和历史的环境下演变而来的。循证医学有限的诠释能力，尽管有着无可争辩的长处，但始终阻碍了基层医疗护理人员采用更人道主义的护理方法。这点证据非常明显，事实上医疗护理专业的学校教育课程中就没有关于暴力和老年人虐待的内容。对于筛查暴力问题的伦理考虑是合情合理的并且应当先于临床论述。不询问虐待问题的总体危害显然是更大的，既将受害者置于危险之中又难以发展信任关系，比例行筛查缺乏科学依据导致的危害大得多。相反地，开启一个交流渠道，从事临床伤口及疾病治疗方面之外的治愈，这好处远远大于追求科学严谨的好处。虐待、健康问题和死亡率之间的高相关性，怀疑率水平以及自发报告水平的低下，以及病人的高接受程度的证据，使得不去例行筛查老年人虐待在伦理上不可接受。然而，基层医疗护理人员对虐待缺乏认识不能只归咎于医学模型以及教育缺乏。医疗护理提供者在遇到虐待时经历的无意识过程，以及许多制度和组织性障碍需要被特别关注。关键是要承认医疗护理工作者的感受并把他们看作是社会的一部分，而不是凌驾其上。跨领域培训和实践被认为是紧要的克服这些障碍并且从人道主义角度有效地处理老年人虐待的方法。

目前这篇综述的不足之处这篇综述有一些重要的不足之处。因为关于老年人对筛查接受程度以及处理老年人虐待的障碍的具体文献很少，这篇综述参考了关于家庭暴力的文献。因此，它所作的结论需要被小心对待以免陷入和文中批评的专业偏误一样的错误中。不过，由于基层医疗护理体系同时对抗家庭暴力和老年人虐待问题，所以这篇综述中所识别的无意识过程和制度障碍或许可以激发具体的研究和实践。

Lack of agreement on the language used and definitions have been addressed throughout this review as stumbling blocks for effective practice. It is crucial not to confuse the philosophical discourse and the realities of everyday practice; while definitions are important in that they synthesize the central themes on which research and practice should be based, parallel action to help current sufferers is imperative. Beyond the lack of agreement on how to define elder abuse, a critical example is the discussion on whether screening or enquiry should be applied. The supremacy of the medical model, with its implications of objective scientific meaning, is challenged. Language is not owned by any one discipline: it evolves within social and historical contexts. The narrow interpretation of evidence-based medicine, while having incontestable strengths, consistently prevents PHC workers from adopting a more humanistic care approach. This is clearly evident by the virtual absence of violence and elder abuse in educational curricula of the health care professions. The ethical concerns around screening for violence are legitimate and should precede the clinical arguments. The overall harm of not asking about abuse is markedly greater, both with regard to the danger of leaving a victim at risk and in the development of a relationship of trust, than the harm resulting from lack of scientific evidence for routine screening. Conversely, the benefits of opening up a communication channel pursuing healing beyond the clinical aspects of treating an injury or disease are much greater than the benefits of scientific rigour. The high association between abuse, health problems and mortality, low levels of suspicion and low levels of self-reporting, together with the evidence gathered of high acceptance by patients, makes it ethically unacceptable not to screen routinely for elder abuse. However, the lack of recognition of abuse by PHC professionals cannot be blamed solely on the medical model and lack of education. Unconscious processes that health care providers experience while confronted with abuse, along with multiple institutional and organizational barriers, require special attention. It is crucial to acknowledge the feelings of health care workers and see them as part of society, not above it. Interdisciplinary training and practice have been recognized as imperative to overcome these barriers and to deal effectively with elder abuse from a human-rights approach.

Limitations of the current review This review has some important limitations. Since specific literature on the acceptability by older persons of screening and on barriers to dealing with elder abuse is scarce, this review has looked at the literature on domestic violence. Therefore, it draws conclusions that need to be treated with caution in order to avoid falling into the same professional biases that were critiqued in this paper. However, as PHC settings are confronted with both domestic violence and elder abuse, the unconscious processes and institutional barriers identified in the review can stimulate specific research and practice. 64

这篇综述没有分析到老年人虐待的所有方面。相对地，它主要集中在和虐待识别有关的多种障碍方面。然而，在还未充分理解老年人虐待自身复杂性的情况下，鉴别它的工作也难免失败。这篇综述无意装作覆盖了所有查得到的文献，因此，无法做出归纳性的结论。

对行动的启示英国下议院卫生委员会所作的关于老年人虐待的报告(15)中制订了行动愿景，并且事实上正在发生，比如目前正在进行的的大规模国家老年人虐待流行率研究，牵涉到数个学科。尽管实践、研究和培训是紧密相关的，为了方便的目的这里将它们分成了几个单独的小节并且将行动要点列了出来。

政策和实践最终，唯一可以了解如何提高筛查和转诊并克服各种障碍的方法就是实践，并且全面跨领域行动已经被认为是良好实践的必要条件。 l

需要政策变化来处理年龄歧视和老年人虐待。

l

筛查是第一步。当找到有嫌疑的老年人虐待，必须有进一步的评估和合适的转诊跟进。转诊以及后续和志愿部门的联系需要成为过程的一部分。

l

为了成功地维持一个筛查项目的实施，需要有正式清晰的程序和机制、定期的案例回顾、发展工作伙伴和定期反思的活动。

l

参与设计和改良筛查工具的专业数量和老年人越多，那么这个工具越容易被不同专业的工作人员以及病人所接受。

l

敏感以及建立信任关系是良好实践的关键。各个关系层面都需要改善：在从业者和病人之间，在从业者之间，在从业者和卫生管理人员和政策制订者之间。

l

保密、报告和信息共享问题需要被讨论确定并正式化。

l

为了有效地处理虐待案件、讨论可能的嫌疑、阐明程序以及克服个人障碍，需要实施跨领域的反思活动和例行监督指导。

l

跨领域的实践需要包括到媒体和政策制订者，以便于提高公众对广泛传播的老年人虐待的重要性的了解并公开的谴责这种行为。

This review did not analyse all aspects of elder abuse. Rather, it concentrates on the multiple barriers related to its recognition. However, without understanding the complexities of elder abuse itself, the task of identifying it will fail. This review does not pretend to have covered all available literature and, therefore, generalized conclusions could not be made.

Implications for action The report on elder abuse by the United Kingdom House of Commons health committee (15) has created an expectation for action, which in fact is taking place, such as the current large-scale national prevalence study of elder abuse currently taking place, involving several disciplines. While practice, research and training are closely interrelated, for practical reasons they are divided here in separate subsections and are listed as points for action.

Policy and practice Ultimately, the only way to know how to improve screening and referrals and to overcome the multiple barriers is practice, and sound interdisciplinary action has been recognized as an imperative for good practice. l l

l

Policy change is needed to address ageism and elder abuse. Screening is a first step. When elder abuse is suspected, further assessment and appropriate referrals must follow. Referrals and ongoing contact with the voluntary sector need to be part of the process. Formal and clear procedures and mechanisms, regular case reviews, peer staff development and regular reflective practice need to be in place in order to sustain the implementation of a successful screening programme. The more disciplines and older persons are involved in the design and refinement of a screening tool, the more the tool will be accepted by both professionals of different disciplines and patients. Sensitivity and trust-building are key for good practice. Changes are needed at the relationship levels: between practitioners and patients; between practitioners, between practitioners and health administrators and policy-makers. Issues of confidentiality, reporting and information-sharing need to be discussed, agreed and formalised. Interdisciplinary reflective practice and routine supervision need to be implemented in order to deal effectively with abuse cases, discuss possible suspicions, clarify procedures and overcome personal barriers. Interdisciplinary practice needs to include the media and policy-makers in order to raise awareness of the widespread magnitude of elder abuse and to publicly condemn it.

研究 l

为了理解不同类型的老年人虐待以及它们如何互相起作用，既需要定量研究也需要定性研究。

l

老年人虐待研究中的一个重要的缺陷就是缺少老年人自己的声音，尤其是涉及到对实施例行筛查的接受程度。在基层医疗护理环境下使用性别敏感的方法对老年女性和老年男性同时进行的定性研究或许可以了解他们的观点。

l

包含老年人群体的参与过程和行动研究应当被提上研究议程。

l

牵涉到大型代表性样本和使用标准化方法的人口基础研究对于适当地估计老年人虐待规模并设计合适的政策是非常必要的。

l

为了检验风险因素在何种程度下加重了老年女性的发病率，应当进一步研究更年期对于家庭暴力的影响。

l

对于不同基层医疗护理职业使用筛查工具有效性的测试，以及持续的对专业人员内部和志愿者部门之间相互交流的评估有必要进行。

l

在实施一个筛查和转诊项目时观察并鉴别关键要点，有助于了解需要什么具体类型的监督指导。

培训关于老年人虐待的基础教育需要被纳入护理专业的正式课程中，与此同时，教育内容需要超出仅仅识别虐待和忽视的迹象与症状。护理提供者会面临的伦理问题的巨大复杂性，包括他们遇到虐待时自己的感受，需要被给予细致的考虑。 l

跨领域以及跨机构的培训对于成功实施筛查和转诊程序而言至关重要。

l

培训需要包含更广泛的社会问题和障碍，比如性别方面和年龄歧视，并提供反思个人态度和群体过程的机会。

l

老年人，包括那些经受过老年人虐待和家庭暴力的幸存者，应当被纳入教育活动中。

l

家访以及拓广到社区范围的出访可以是正式培训的中心要素，因为对老人背景的个人了解可以增进病人-从业者之间的信任。

l

基层护理以外的其他职业人士的出访与培训可以被考虑。例如，关于老年人虐待的法官培训研讨会被证实非常成功。学校老师或许是很好的培训目标群体，以推进几代人之间的团结。

l

涉及横跨社会的创新性合作关系的创造性的教育场所，比如电视网络和工业/工作场所，需要被更多地探索。

Research l

l

Both quantitative and qualitative research is needed in order to understand the different types of elder abuse and how they interact with each other. A crucial gap in elder-abuse research is the missing voices of older persons themselves and specifically regarding acceptability for implementation of routine screening. Qualitative research at PHC settings with both older women and older men using a gender-sensitive approach may shed light on their views. Participatory processes and action research involving older people’s groups should be considered to bring forward the research agenda. Population-based studies involving large and representative samples and using standardized methodologies are necessary to properly estimate the scale of elder abuse and to design appropriate policies. Further research on the effects of menopause on domestic violence should be conducted in order to check to what extent the risk factors add to a double burden of morbidity among older women. Research to test the effectiveness of using screening tools by the different PHC professions is required alongside ongoing evaluations on the interactions between professionals and with the voluntary sector. Observation and identification of crucial points when implementing a screening and referral programme, may inform the specific type of supervision that is needed.

Training While basic education on elder abuse needs to be included in the formal curricula of the caring professions, education needs to move beyond the recognition of the signs and symptoms of abuse and neglect. Careful consideration to the great complexity of ethical issues faced by care providers, including their own feelings, while facing abuse needs to be given. l

l

Interdisciplinary and interagency training sessions are crucial for implementing screening and referral procedures successfully. Training needs to incorporate wider societal issues and barriers, such as gender dimensions and ageism, as well as an opportunity for reflection on personal attitudes and on group processes. Older persons, including survivors of elder abuse and domestic violence, should be involved in educational activities. Home visits and outreach to the community could be a central element of formal training, as personal knowledge of the older person’s environment increases patient–practitioner trust. Outreach and training with other professions other than primary care could be considered. For example, training seminars of judges on elder abuse has proved very successful in the United States. School teachers could be a good target group for training to promote intergenerational solidarity. Creative educational venues that involve innovative partnerships across society such as television networks and industry/workplaces, need to be explored more. 68

结论性评注老年人需要了解他们的权利。在这方面，基层医疗护理体系和专业人员可以成为老年人的拥护者。基层医疗护理人员应当筛查老年人虐待作为一系列干预措施的第一步。但是它实施的复杂性需要在一个建立起跨领域框架、持续的研究、评估以及能力的情况下完成。除了个人安排和各种可能强调实践的理论外，基层医疗护理人员之所以选择护理职业是因为他们关心。医疗护理无法在泡影或者社会的其他部分找到。医疗护理需要满足病人的需求并且建立伙伴关系，同时需要考虑专业人员自身的感受以及他们生活的现实。

Concluding remarks Older persons need to be aware of their rights. In this regard, PHC settings and professionals can be advocates for older people. PHC workers should screen for elder abuse as a necessary first step in a chain of interventions. But its complex implementation needs to be accomplished within an interdisciplinary framework, ongoing research, evaluation and capacity building. Beyond any personal agendas and different theories that may underline practice, PHC workers have chosen a caring profession because they care. Health care cannot be seen in a bubble or above or outside the rest of society. Health care needs to adapt to the needs of its patients/clients while forging partnerships and taking into consideration the professionalsâ&#x20AC;&#x2122; own feelings and the realities in which they live.

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