A/HRC/18/37 often preferred by the patient. It also reduces reliance on formal or institutional care, minimizing the burden on these limited resources. However, older persons are often placed, or find themselves, in informal care without a thorough assessment, exposing them to risk. Such risks include inadequate care by a person who is not equipped to provide the necessary care, as well as the risk of abuse by a caregiver. Numerous States have introduced initiatives to provide support to carers, such as financial support in lieu of lost income, and respite care, which allow older persons to stay at home as long as possible, whilst receiving goodquality care.29 48. Formalized long-term care of both types is already prevalent in much of the developed world. In the developing world, traditional social dynamics are also undergoing changes due to various globalizing factors. Families play a steadily less prominent role as primary health-caregiver of older persons, and government institutions and medical professionals are assuming a bigger role in care-giving. The situation is exacerbated in developing countries by the lack of adequate institutional mechanisms and absence of measures to protect the rights for older persons in the context of external and non-family care. Developed countries, where infringements on the rights of older persons also take place, feature only relatively better in developing such mechanisms. 49. The Special Rapporteur stresses the impact of institutionalization on the autonomy of older persons and its often harmful effect on their dignity. Loss of full independence, restricted freedom of movement and lack of access to basic functions would cause feelings of deep frustration and humiliation to any individual. Older persons are no exception to this. It is essential that complaints mechanisms are put in place to address practices that unnecessarily restrict liberty and autonomy of older persons and to enable them to reclaim their dignity. 50. The Special Rapporteur is particularly concerned about unreported violence directed against older persons in care. As with other vulnerable and marginalized groups, special attention is needed to protect older persons from abuse and to ensure that their rights are not violated in settings where they might be especially prone to violations. Abuse of older persons is defined as 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. 30 It is important to note that abuse is often insidious, limiting the autonomy of older persons in subtle ways. It can take various forms, including physical, psychological, emotional, sexual or financial abuse, or be affected by neglect. 51. The abuse of older persons can be complex when the abusing caregiver is a relative or a family member. The frequency of elder abuse in the domestic setting, including abuse perpetrated by family members, was estimated by one study as occurring in anywhere between 2 and 10 per cent of all cases. In an institutional setting incidences of abuse are even harder to ascertain Abuse may also take the form of prejudicial and discriminatory attitudes and acts, which manifests itself through paternalism towards older persons in care, leaving them feeling humiliated, infantilized, and robbing them of the identity they otherwise have as human beings. 52. In some instances, health-care workers themselves may not even recognize instances of abuse. Health-care workers should therefore be trained and assisted in identifying possible cases of abuse. Models of such training and intervention are used in cases of domestic abuse and may serve as workable models for dealing with recognition and treatment of the abuse of older persons. Health-care workers need to become aware of the 29 30 OECD, Long-term Care for Older People (OECD, Paris, 2005), p. 11-12. WHO, The Toronto Declaration on the Global Prevention of Elder Abuse (WHO, Geneva, 2002), p. 3. 13