Thirty-nine years ago in 1975, a very short report in the form of a letter was published in the august British Medical Journal. The writer was a Dr G.R. Burston and the title of the article was Granny-battering.
Dr Burston wrote then that "it is about time that all of us realised that elderly people too are, at times, deliberately battered". Since that first report of what is now called elder abuse appeared in medical literature, there has been more attention to this very much hidden problem. Together with child abuse and spousal violence, it is the unholy trinity of domestic violence. But the research, interventions and awareness in this field lag far behind the other two.
A recent feature in The Sunday Times highlighted the issue of elder abuse - which encompasses physical, psychological and sexual abuse, neglect, as well as financial exploitation of people aged 60 and older - in Singapore.
The important service that this story has done in placing elder abuse in the public spotlight is indisputable. It was based on a study done by Trans Safe Centre, which is an agency that handles elder abuse. One of the findings was that 42 per cent of the perpetrators have "suspected or confirmed mental illness".
It could be that people with mental health issues find it more difficult to look after an elderly person, but some caution must be exercised in the interpretation of this finding, which is drawn from 93 cases of substantiated elder abuse. This highly selected and relatively small group is not representative of the actual situation. It might not only be erroneous to conclude that mentally ill people are more likely to be abusers but, in doing so, it would also further stigmatise those who are already discriminated against and marginalised in our society.
The converse is probably the case. Mentally ill people are often the victims of crime and abuse - and elderly people with dementia are particularly vulnerable, more so than those without dementia.
In a scholarly review of 28 different studies from different countries published this year in the journal Health Affairs, the rate of physical abuse of elderly people with dementia ranged from 27.9 per cent to 62.3 per cent.
The National Elder Mistreatment Study in the United States, on the other hand, reported that only 1.6 per cent of its cognitively intact elderly respondents had experienced physical abuse. Dementia is more than a loss of memory; it is also a progressive loss of comprehension, judgment, insight, speech and physical function. In the earlier stages, people with dementia can be easily cheated of their money and assets.
Such was the salutary case of Brooke Astor. She was New York's unofficial first lady who, with her fabulous wealth, made philanthropy her career. Later in life, she developed Alzheimer's disease. After her death at the age of 105, her only son was accused of neglecting her care (including forcing her to sleep on a urine-drenched couch) and of stealing her money to enrich himself - for which he was subsequently convicted.
Elder abuse in people with dementia often involves a complex interaction between the victim and the perpetrator. On one side of the calculus are the vulnerability, dependency and the psychological and behavioural change in the individual, which might make the person agitated and aggressive. This can provoke retaliation from the caregiver - with verbal abuse, blows and neglect.
On the other side is the wide cast of abusers who include family members, paid caregivers, friends and professional health-care workers. Undoubtedly, there are unscrupulous and predatory individuals who exploit the vulnerable and the weak, but the inexorable slide of dementia towards decrepitude, infirmity and death exacts an increasing toll on their caregivers.
A number of studies have shown that caregiver burden and stress are among the most common risk factors associated with elder abuse. If the relationship prior to the onset of dementia was already wretched and devoid of affection and warmth, or marred with conflict, it would make elder abuse all the more likely.
Just as history is important, so is the setting. Being cooped up with a person with dementia - the sociologists called this "living in a shared living environment" - and being cut off from other people are recipes for elder abuse.
Intriguingly, a study in Hong Kong that was published in 2011 in the International Journal Of Geriatric Psychiatry found that having a domestic help seems to reduce the likelihood of elder abuse. It could be that the additional help reduces caregiver burden and stress, and the presence of a "non-family member" within the household places a restraining hand.
Elder abuse is a complex problem that would require a raft of measures ranging from better support of caregivers and more training and incentives for those who take care of our elderly, to legislation to provide the legal instruments to better protect the elderly. There should be better public awareness and education. How many people in Singapore, for instance, know the tell-tale signs of elder abuse or are aware of the existence of the Elder Protection Team and how to make a report?
And there are many gaps in our present understanding of elder abuse in Singapore. We do not know how extensive it is, what are the engendering factors, or what are the policies and interventions that would be effective to prevent or reduce this problem.
Until we understand this phenomenon of elder abuse better, any one of us could end up being a victim, and any one of us might even end up being a perpetrator.
The writer is the vice-chairman, medical board (research), at the Institute of Mental Health.