ate Dr F* was a successful gynaecologist who kept active till her mid-90s. When she retired as a gynaecologist, she stayed active with her philanthropy and opened a school for poor children in a suburb of Lahore, and a free clinic in an adjacent lot which she also owned. She constructed a clinic building, and with the help of her daughter and son-in-law (who were living in the United States) employed a husband-and-wife doctor team to run the clinic. This couple introduced her to a pir who convinced Dr F to let his religious organisation get involved in running the operations of the clinic and school. When she was signing the papers for transferring operations to this organisation, she did not realise that she was also transferring her valuable property to them. Her family did not realise that she had developed dementia and was not able to understand the nuances of legal documents. Dementia can creep up, and is difficult to recognise in high functioning older adults, when in an early stage. By the time the family found out that this 94-year-old doctor had been duped in early stages of dementia, it was too late. When Dr F and her family tried to get legal help, they were threatened. The doctor was crushed and became depressed. Her daughter later told me that the fraud had destroyed her mother. Till her dying moment, Dr F kept asking her daughter about the outcome of the lawsuit they had filed against the perpetrators of the fraud; her daughter eventually had to lie. Dr F was told she had got her clinic back.

Mr D* was a successful businessman whose children were all settled abroad. He lived in Lahore with his wife. Her death left a void in his life. His children did not realise that he had developed dementia in his 80s. When he died and his children arrived for the funeral, they found a much younger woman living in the house. They were told that she was his wife. Six months prior to his death, a ‘man of religion’ had convinced Mr D to marry this young woman as she would care for him and provide comfort. The woman later told the family that they got married six months prior to Mr D’s death, and he had transferred all his assets to her. The children had to not only deal with the loss of their father, but also the shock of discovering this development.

These cases highlight not only elder abuse but also a lack of resources available for vulnerable older adults in Pakistan. Dementia prevalence is 30 percent and higher in persons over the age of 70. It can remain unrecognised and undiagnosed, especially in high functioning persons. Cognitive impairment puts a person in the vulnerable category, hence becoming a potential victim of abuse.

The World Health Organisation defines elder abuse as “a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is expectation of trust, which causes harm, or distress to an older person.” While a variety of circumstances are considered elder abuse, it does not include general criminal activities against older adults, such as home break-ins, robbery or muggings in the street, etc.

In the United States, it is mandatory to report elder abuse to adult protective services (a law enforcement agency). The government should create such services for older adults. This department should have trained officers and social workers to investigate such cases.

The WHO estimates that 15.7 percent of people 60 and older experience elder abuse. These numbers are thought to be a low estimate as many instances go unrecognised and unreported. Incidents of elder abuse are projected to increase as the population of the world ages. Various forms of elder abuse are recognised: financial, physical, psychological, sexual. Intentional or unintentional neglect and self-neglect also falls in this category. Consequences of elder abuse are serious and can include declining functional status, sense of helplessness, premature mortality and increased morbidity, malnutrition, depression and death.

Over the years, most countries in the Global North have founded government agencies and special departments focusing on elder abuse. Elder abuse exists in Pakistan. It is unrecognised and underreported, and is a sensitive issue due to cultural norms and values. The elderly persons are supposed to be revered in our society, and it is hard for us to admit that elder abuse exists. However, early intervention could have a greater impact on promoting health and well being of vulnerable older people.

There is no existing population-based data looking at the prevalence of elder abuse in Pakistan. According to the Global Age Watch Index, Pakistan is ranked 5^th worst country for older population. While this index looks at multiple factors, we can assume that lack of resources and knowledge will lead to higher prevalence of elder abuse. Pakistan has ratified the Madrid International Plan of Action on Ageing (MIPAA 2002) which focused on building all-age-inclusive society. Despite this, Pakistan’s elderly population is suffering due to lack of resources for health and prevention of abuse.

We need to conduct population-based surveys to analyse existing problems and find ways to mitigate these issues. We need to have laws protecting elders from abuse, and have a special branch of law enforcement focused on protection of elders from abuse. In the United States, it is mandatory to report elder abuse to adult protective services (a law enforcement agency). The government should create such services for older adults. This department should have trained officers and social workers to investigate such cases. While financial abuse is highlighted in this piece, all forms of abuse described above are happening in our communities. We need to train healthcare professionals (nurses, doctors, pharmacists) to recognise special healthcare needs of the geriatric population. Legal fraternity also needs to pay attention to elder abuse and provide training to lawyers regarding elder abuse. Bar Councils across the country need to provide opportunities for persons to complain against lawyers who are helping perpetrators commit financial elder abuse.

*Names have been hidden to protect identities

The writer is a US-based geriatrician who has held positions at University of Michigan, Indiana University, University of Wisconsin and New York University. She is currently working at the University of Chicago health system. She can be reached at amnabuttar@gmail.com, and on Instagram @dramnabuttar