《The Medical Republic》案例分享——安妮的痛苦：一个虐待老年人的故事Annie's Anguish：a Story of Elder Abuse

Leon Piterman，梁艳嫦（译），杨辉（译）

【编者按】 澳大利亚的全科医生具有行业自律性，体现在其自行制定行业标准、自主进行资质考核及自主执业等方面，也体现在《The Medical Republic》这一共享平台上。Leon Piterman是医学学士，医学博士，教育学硕士，英国医生学会会员，澳大利亚全科医生学会会员，Monash University副校长、全科医学教授，从事全科医学临床服务近40年，研究兴趣为慢性病管理、心理健康、医学教育。Piterman教授建议我国的全科医生应培养“共和”思想，以为全科医学领域提供更多的平等交流机会。目前Piterman教授定期为《The Medical Republic》撰写文章，本刊深受“医学共和”思想的启发，特邀本刊编委Monash University杨辉教授对Piterman教授的文章进行编译，并进行连载刊登！根据2018年世界家庭医生组织家庭暴力特殊利益团体（WONCA Special Interest Group on Family Violence）发出的公告，过去1年里有近1/6的老年人遭受了各种形式的虐待。虐待老年人主要包括躯体虐待、心理虐待、经济虐待及漠不关心4种常见形式，经济虐待是指监护人不正当地应用老年人的收入和经济来源，或者未使用可得到的资金或经济来源来维持或恢复老年人的健康、幸福。本期Piterman教授为我们讲述了一例遭受财务方面虐待的老年人的故事，以提醒全科医生在为老年人提供健康服务时，应以家庭为单位，关注其与家庭成员间的关系以及是否遭受了虐待，敬请关注！

汤姆和安妮是我所执业诊所的长期就诊患者，20世纪50年代初结婚时，他们搬进了墨尔本东南郊区的多面砖房。墨尔本东南郊区在划分成为住宅区之前，是蔬菜瓜果的种植地。那个时候几乎不用担心城市绿化带的问题，铁路线和火车站也都建设得很到位，没有现在面临的基础设施“追赶”不上都市扩张速度的问题。毕竟，这个郊区距离墨尔本的中央商务区仅16 km，不像现在的城市地铁要向外延伸超过50 km。

汤姆和安妮的家庭，也跟着他们的社区一起成长。他们的3个孩子，2个女儿、1个儿子，都是由我所在诊所的全科医生在当地社区医院接生的。现在，这家社区医院已经变成了肿瘤中心，悲伤的是，它已经不再是新生命诞生的地方，而是很多人离世的地方。而在这个医院里，也已经没有全科医生可以施展的地方。

汤姆是一个高大、强壮、英俊的男子。在第二次世界大战的太平洋战场服过兵役，回国后做了木匠学徒。汤姆是一个有潜力的运动员，战争结束后，收到了好几家足球俱乐部的邀请。如果换作现在，汤姆可能会成为球星，然后签下利润丰厚的合同。但当时，因为结婚后孩子们相继出生，汤姆选择了木匠职业来养家糊口。

安妮现在70多岁，已经开始出现阿尔茨海默病的早期症状。汤姆说安妮记不住自己把东西放在了什么地方，他不放心让安妮一个人购物或者做饭，而且要经常提醒她去洗澡。安妮去老年病专家处就诊过几次，接受了一系列的检查，最终被确诊为阿尔茨海默病。

这时，他们的大女儿茱伊主动提出，会带安妮每周出去购物1～2次，然后利用这些外出机会与母亲一起喝咖啡、吃三明治。汤姆非常感激女儿的帮助，这样他就可以有时间收拾花园，或者去退伍军人俱乐部找老战友回忆往事。茱伊的妹妹珍妮丝、弟弟埃里克也很高兴，因为他们都有全职工作，没有时间照顾安妮。

这样的安排一直愉快地持续了8、9个月，直到有一天汤姆接到了银行的电话。银行雇员询问汤姆，是否知情储蓄账户的额度已经快消耗殆尽。这个储蓄账户绑定了安妮的信用卡，近6个月来，账户里的额度通过定期取现、信用卡支付给在线赌博公司的方式，减少了35 000澳元，目前账户仅剩下5 000澳元。

汤姆来找我，泪流满面、浑身颤抖、震惊、羞愧。他说，他质问过茱伊，茱伊承认自己赌博，并且承诺会把钱还回来。茱伊的妹妹和弟弟希望警察能介入这件事，但汤姆不能接受与亲人对簿公堂，因为那样可能会让茱伊被关进监狱。茱伊提出，会和丈夫詹姆斯一起在12个月内把钱还回来，汤姆接受了她的方案。但这个家庭的生活，不会再恢复到以前的样子了。

随着人口老龄化进程的加快，虐待老年人的事件逐渐增多。目前年龄为65岁及以上的老年人口数约占15%，而在80岁及以上的老年人中约20%患有某种形式的意识障碍，虐待老年人的潜在风险较高。虐待老年人不仅局限在家庭里面，在养老机构也常有发生。维多利亚州皇家家庭暴力委员会（Royal Commission into Family Violence）根据维多利亚警方和维多利亚老年人权益局提交的重要报告数据，提出了虐待老年人这一问题的重要性［1］。

虐待可以发生在生理、性、情感、财务等很多方面，比如安妮遭遇的情况。当虐待发生在家庭环境中时，通常很少会向警方报告，多数老年人只能默默忍受。据估计，5%～6%的澳大利亚老年人可能会遭到某种形式的虐待，且女性受害者多于男性。一般来说，男性是施虐者，但50～54岁的女性成为施虐者的可能性也较大。安妮的女儿茱伊52岁，符合维多利亚老年人权益局报告中描述的施虐者类型。多数被虐待的老年人年龄为70～84岁，多数施虐者的年龄为35～54岁。92%的施虐者与受害者具有一定关系，其中40%为受虐者的儿子，27%为受虐者的女儿，5%为受虐者的丈夫［1］。

很多全科医生的老年患者遭受过虐待，或未来会遭受虐待。重要的是，在某些特定情况下，我们可以通过一些简单的提问，婉转地向老年患者提出这些问题：你家庭成员的关系怎么样？你和子女相处得怎么样？你自己管理财务吗？你有安排委托人吗？汤姆信任他的女儿茱伊，但茱伊辜负了父亲的信任，并导致了家庭关系的永久性破坏。在接下来的6个月里，汤姆的健康状况急转直下，安妮被送进了养老机构。1年后，汤姆和安妮相继离世。我不知道他们的死亡证明书上，是否表明了真正死因。

译 者 注：（1） 多 面砖 房（triple-front brick veneer），澳大利亚战后（1050—1970年）的民居建筑风格。特点为：正面有多个房间，错落排列，窗户面对前院；墙壁是单层砖，黄色或棕色；房顶倾斜；窗子为铝合金框；房间内有地板，墙壁上少有装饰。这种砖房是澳大利亚的“经济适用房”，造价较低，缺乏艺术感，是为了适应战后人口激增、住房需求快速增长的情况。（2）蔬菜瓜果种植地（market-garden territory），一般位于城市郊区，每日向城市供应新鲜蔬菜和水果。但随着城市化，这些种植地被改建为住宅区，种植地逐渐外移。（3）绿色带（green wedges），是城市的生态肺。（4）全科医生在社区医院接生孩子。澳大利亚传统的全科医生是在社区医院里接生孩子或进行小手术的，但目前这种传统的全科医生在城市地区基本不存在，部分农村地区仍然存在。（5）退伍军人俱乐部（RSL），澳大利亚的退役和服务联盟，为从世界大战战场归国的退伍军人、牺牲军人家属提供同情和支持的社会组织。

志谢：特别感谢原文出版者《The Medical Republic》同意将此文编译后刊登于《中国全科医学》。

［1］Royal Commission into Family Violence.Royal commission into family violence full report［J］.Summary and Recommendations，2016，5（27）：1353-1384.

Tom and Annie were long-standing patients at our clinic.They had moved into their triple-front brick veneer in the south-eastern suburb of Melbourne when they married in the early 1950s.

This suburb was market-garden territory until the subdivisions hit.There was little or no talk of green wedges at that time，and a railway line and station were already in place，unlike some of the infrastructure "catch up" problems we now face in our ever-expanding metropolis.After all，this suburb is only 16 km from the CBD，unlike the current outer-metro sprawl which extends beyond 50 km.

Tom and Annie's family grew，as did their community.Their three children（two daughters and a son） were all delivered in the local hospital by GPs from our clinic.This community hospital is now a cancer centre.Babies no longer enter the world in this place；sadly，many people leave it.GPs have no role to play in this organisation.

Tom was a tall，strong，good-looking man who had completed a carpentry apprenticeship after returning from the Second World War where he served in the Pacific.He was a talented athlete whose skills were sought by several football clubs immediately after the war.Had he lived today，he may well have played football at an elite level and would have secured a lucrative contract.Recently married and soon with a growing family，Tom instead turned to his vocation as a carpenter to earn a living and support his family.

In her mid-70s，Annie began to show early signs of dementia.Tom highlighted the difficulty she was having remembering where she placed things，she could no longer be trusted to go shopping on her own or cooking meals and progressively needed reminding about showering.A series of tests and visit to a geriatrician confirmed the diagnosis of Alzheimer's dementia.

It was at this stage that Joy，their eldest daughter stepped in to help.She offered to take her mother shopping on a regular basis，once or twice a week，sharing coffee and sandwiches on these outings.Tom was very appreciative as it gave him time to spend in the garden or share some memories with old mates at the local RSL.

Joy's siblings，Janice and Eric，were also happy，particularly as they had full-time jobs and could not afford the time to care for Annie.

This arrangement continued happily for eight or nine months，until Tom received a call from the bank asking him if he was aware that their savings account which was linked to Annie's credit card had been progressively depleted over the past six months with $35 000 being removed over this time，through a mixture of regular cash withdrawals and credit card payments to an online betting agency.There was now only $5 000 left in the account.

Tom came to see me.He was tearful，shaking，shocked and mortified.He had confronted Joy，who admitted to a gambling problem and promised to pay the money back.Her siblings wanted the matter reported to the police.Tom could not bear the thought of a court case and the possibility of Joy spending time in jail.He agreed to accept Joy's offer，who，together with her husband James，undertook to pay the money back over a 12-month period.Life for the family was never the same again.

Elder abuse is becoming increasingly common as our population ages.With almost 15% of the population aged over 65，and up to 20% of people aged over 80 expected to suffer some form of dementia，the potential for elder abuse increases.

Elder abuse is not confined to family settings and often takes place in institutional settings.The Victorian Royal Commission into Family Violence devoted a section to elder abuse with important submissions from Victoria Police and Senior Rights Victoria.

Abuse may be physical，sexual，emotional or financial in nature，as was the case with Annie.When it occurs in family settings，it is often under-reported to police.Shame takes over.It is estimated that 5% to 6% of elder Australians may be affected by some form of abuse，with women affected more than men［1］.

Generally，males are the perpetrator，with the exception of perpetrators in the 50-54 year age group where women are more likely to be perpetrators［1］.

Joy，Annie's daughter was 52.Joy fits nicely the pattern described in The Senior Rights Victoria Study.Most elder abuse victims are aged 70-84，most perpetrators are aged 35 to 54，92% of perpetrators are related to the victim，40% are sons of the victim and 27% are daughters.Only 5%are husbands.

Many GPs will have older patients who have been abused，or will be abused in the future.

It is important that，in certain circumstances，we tactfully raise the subject with elderly patients by asking some simple questions：（1）How are relations in your family?（2）How do you get on with your children?（3）Do you manage your own finances?（4）Have you arranged power of attorney?

Tom trusted his daughter.That trust was misplaced and abused and family relations were permanently destroyed.

Tom's health deteriorated rapidly over the next six months and Annie was admitted to nursing home.A year later both were dead.

I was left wondering what to write on the death certificates as the true cause of death.Reference

［1］Royal Commission into Family Violence.Royal commission into family violence full report［J］.Summary and Recommendations，2016，5（27）：1353-1384.