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Elder Abuse

by Daniel B. Kaplan, PhD, MSW, Barbara J. Berkman, DSW, PhD

Elder abuse is physical or psychologic mistreatment, neglect, or financial exploitation of the elderly.

Common types of elder abuse include physical abuse, psychologic abuse, neglect, and financial abuse. Each type may be intentional or unintentional. The perpetrators are usually adult children but may be other family members or paid or informal caregivers. Abuse usually becomes more frequent and severe over time. Fewer than 20% of abuse cases are reported; thus, physicians must remain vigilant in identifying elderly patients at risk of mistreatment.

Physical abuse is use of force resulting in physical or psychologic injury or discomfort. It includes striking, shoving, shaking, beating, restraining, forceful feeding, and unwarranted administration of drugs. It may include sexual assault (any form of sexual intimacy without consent or by force or threat of force).

Psychologic abuse is use of words, acts, or other means to cause emotional stress or anguish. It includes issuing threats (eg, of institutionalization), insults, and harsh commands, as well as remaining silent and ignoring the person. It also includes infantilization (a patronizing form of ageism in which the perpetrator treats the elderly person as a child), which encourages the elderly person to become dependent on the perpetrator.

Neglect is the failure or refusal to provide food, medicine, personal care, or other necessities; it also includes abandonment. Neglect that results in physical or psychologic harm is considered abuse.

Financial abuse is exploitation of or inattention to a person’s possessions or funds. It includes swindling, pressuring a person to distribute assets, and managing a person’s money irresponsibly.

Although the true incidence is unclear, elder abuse appears to be a growing public health problem in the US. In a large US urban study of people 65, 3.2% were victims of physical abuse, psychologic abuse, or neglect. Because certain forms of abuse (eg, financial exploitation) were not included, the actual incidence of mistreatment was probably higher. In Canadian and western European studies, incidence of abuse was comparable to that in the US.

Risk Factors

For the victim, risk factors for abuse include impairment (chronic disorders, functional impairment, cognitive impairment) and social isolation. For the perpetrator, risk factors include substance abuse, psychiatric disorders, a history of violence, stress, and dependence on the victim (including shared living arrangements— Risk Factors for Elder Abuse).

Risk Factors for Elder Abuse

Factor

Comments

For the victim

Social isolation

Abuse of isolated people is less likely to be detected and stopped. Social isolation can intensify stress.

A chronic disorder, functional impairment, or both

The ability to escape, seek help, and defend self is reduced.

Such elderly people may require more care, increasing stress for the caregiver.

Cognitive impairment

Risk of financial abuse and neglect is particularly high.

People with dementia may be difficult to care for, frustrating caregivers, and may be aggressive and disruptive, precipitating abuse by overwhelmed caregivers.

For the perpetrator

Substance abuse

Alcohol or drug abuse, intoxication, or substance withdrawal may lead to abusive behavior. Substance-dependent caregivers may attempt to use or sell drugs prescribed to the elderly person, depriving the person of treatment.

Psychiatric disorders

Psychiatric disorders (eg, schizophrenia, other psychoses) may lead to abusive behavior.

Patients discharged from an inpatient psychiatric institution may return to their elderly parents’ home for care. These patients, even if not violent in the institution, may become abusive at home.

History of violence

A history of violence in a relationship (particularly between spouses) and outside the family may predict elder abuse. One theory is that violence is a learned response to difficult life experiences and a learned method of expressing anger and frustration. Because reliable information about past family violence is difficult to obtain, this theory is unsubstantiated.

Dependence of the perpetrator on the elderly person

Dependence on the elderly person for financial support, housing, emotional support, and other needs can cause resentment, contributing to abuse. If the elderly person refuses to provide resources to a family member (especially an adult child), abuse is more likely.

Stress

Stressful life events (eg, chronic financial problems, death in the family) and the responsibilities of caregiving increase the likelihood of abuse.

For both victim and perpetrator

Shared living arrangements

Elderly people living alone are much less likely to be abused. When living arrangements are shared, opportunities for the tension and conflict that usually precede abuse are greater.

Adapted from Lachs MS, Pillemer K: Current concepts: Abuse and neglect of elderly persons. New England Journal of Medicine 332:437–443, 1995.

Diagnosis

Abuse is difficult to detect because many of the signs are subtle and the victim is often unwilling or unable to discuss the abuse. Victims may hide abuse because of shame, fear of retaliation, or a desire to protect the perpetrator. Sometimes when abuse victims seek help, they encounter ageist responses from health care practitioners, who may, for example, dismiss complaints of abuse as confusion, paranoia, or dementia.

Social isolation of the elderly victim often makes detection difficult. Abuse tends to increase the isolation because the perpetrator often limits the victim’s access to the outside world (eg, denies the victim visitors and telephone calls).

Symptoms and signs of abuse may erroneously be attributed to a chronic disorder (eg, a hip fracture attributed to osteoporosis). However, certain clinical situations are particularly suggestive of abuse ( Clinical Situations Suggesting Elder Abuse).

Clinical Situations Suggesting Elder Abuse

  • Delay between an injury or illness and the seeking of medical attention

  • Disparities in the patient’s and caregiver’s accounts

  • Injury severity that is incompatible with the caregiver’s explanation

  • Implausible or vague explanation of the injury by the patient or caregiver

  • Frequent visits to the emergency department for exacerbations of a chronic disorder despite an appropriate care plan and adequate resources

  • Absence of the caregiver when a functionally impaired patient presents to the physician

  • Laboratory findings that are inconsistent with the history

  • Reluctance of the caregiver to accept home health care (eg, a visiting nurse) or leave the elderly patient alone with a health care practitioner

History

If abuse is suspected, the patient should be interviewed alone, at least for part of the time. Other involved people may also be interviewed separately. The patient interview may start with general questions about feelings of safety but should also include direct questions about possible mistreatment (eg, physical violence, restraints, neglect). If abuse is confirmed, the nature, frequency, and severity of events should be elicited. The circumstances precipitating the abuse (eg, alcohol intoxication) should also be sought.

Social and financial resources of the patient should be assessed because they affect management decisions (eg, living arrangements, hiring of a professional caregiver). The examiner should inquire whether the patient has family members or friends able and willing to nurture, listen, and assist. If financial resources are adequate but basic needs are not being met, the examiner should determine why. Assessing these resources can also help identify risk factors for abuse (eg, financial stress, financial exploitation of the patient).

In the interview with the family caregiver, confrontation should be avoided. The interviewer should explore whether caregiving responsibilities are burdensome for the family member and, if appropriate, acknowledge the caregiver’s difficult role. The caregiver is asked about recent stressful events (eg, bereavement, financial stresses), the patient’s illness (eg, care needs, prognosis), and the reported cause of any recent injuries.

Physical examination

The patient should be thoroughly examined, preferably at the first visit, for signs of abuse ( Signs of Elder Abuse). The physician may need help from a trusted family member or friend of the patient, state adult protective services, or, occasionally, law enforcement agencies to encourage the caregiver or patient to permit the evaluation. If abuse is identified or suspected, a referral to Adult Protective Services is mandatory in most states.

Signs of Elder Abuse

Item

Sign

Behavior

Withdrawal by the patient

Infantilization of the patient by the caregiver

Caregiver’s insistence on providing the history

General appearance

Poor hygiene (eg, unkempt appearance, uncleanliness)

Inappropriate dress

Skin and mucous membranes

Poor skin turgor or other signs of dehydration

Bruises, particularly multiple bruises in various stages of evolution

Pressure ulcers

Deficient care of established skin lesions

Head and neck

Traumatic alopecia (distinguished from male-pattern alopecia by distribution)

Trunk

Bruises

Welts (shape may suggest implement—eg, utensil, stick, belt)

GU region

Rectal bleeding

Vaginal bleeding

Pressure ulcers

Infestations

Extremities

Wrist or ankle lesions suggesting use of restraints or immersion burns (ie, in a stocking-glove distribution)

Musculoskeletal system

Previously undiagnosed fracture

Unexplained pain

Unexplained gait disturbance

Mental and emotional health

Depressive symptoms

Anxiety

Cognitive status should be assessed, eg, using the Mini-Mental State Examination (see Figure: Examination of Mental Status). Cognitive impairment is a risk factor for elder abuse and may affect the reliability of the history and the patient’s ability to make management decisions.

Mood and emotional status should be assessed. If the patient feels depressed, ashamed, guilty, anxious, fearful, or angry, the beliefs underlying the emotion should be explored. If the patient minimizes or rationalizes family tension or conflict or is reluctant to discuss abuse, the examiner should determine whether these attitudes are interfering with recognition or admission of abuse.

Functional status, including the ability to do activities of daily living (ADLs), should be assessed and any physical limitations that impair self-protection noted. If help with ADLs is needed, the examiner should determine whether the current caregiver has sufficient emotional, financial, and intellectual ability for the task. Otherwise, a new caregiver needs to be identified.

Coexisting disorders caused or exacerbated by the abuse should be sought.

Laboratory tests

Imaging and laboratory tests (eg, electrolytes to determine hydration, albumin to determine nutritional status, drug levels to document compliance with prescribed regimens) are done as necessary to identify and document the abuse.

Documentation

The medical record should contain a complete report of the actual or suspected abuse, preferably in the patient’s own words. A detailed description of any injuries should be included, supported by photographs, drawings, x-rays, and other objective documentation (eg, laboratory test results) when possible. Specific examples of how needs are not being met, despite an agreed-on care plan and adequate resources, should be documented.

Prognosis

Abused elderly people are at high risk of death. In a large 13-yr longitudinal study, the survival rate was 9% for abuse victims compared with 40% for nonabused controls. Multivariate analysis to determine the independent effect of abuse indicated that risk of mortality for abused patients over a 3-yr period after abuse was 3 times higher than that for controls over a similar period.

Treatment

An interdisciplinary team approach (involving physicians, nurses, social workers, lawyers, law enforcement officials, psychiatrists, and other practitioners) is essential. Any previous intervention (eg, court orders of protection) and the reason for its failure should be investigated to avoid repeating any mistakes.

Intervention

If the patient is in immediate danger, the physician, in consultation with the patient, should consider hospital admission, law enforcement intervention, or relocation to a safe home. The patient should be informed of the risks and consequences of each option.

If the patient is not in immediate danger, steps to reduce risk should be taken but are less urgent. The choice of intervention depends on the perpetrator’s intent to harm. For example, if a family member administers too much of a drug because the physician’s directions are misunderstood, the only intervention needed may be to give clearer instructions. A deliberate overdose requires more intensive intervention.

In general, interventions need to be tailored to each situation. Interventions may include

  • Medical assistance

  • Education (eg, teaching victims about abuse and available options, helping them devise safety plans)

  • Psychologic support (eg, psychotherapy, support groups)

  • Law enforcement and legal intervention (eg, arrest of the perpetrator, orders of protection, legal advocacy including asset protection)

  • Alternative housing (eg, sheltered senior housing, nursing home placement)

  • Counseling the victim, which usually requires many sessions (progress may be slow)

If victims have decision-making capacity, they should help determine their own intervention. If they do not, the interdisciplinary team, ideally with a guardian or objective conservator, should make most decisions. Decisions are based on the severity of the violence, the victim’s previous lifestyle choices, and legal ramifications. Often, there is no single correct decision; each case must be carefully monitored.

Nursing and social work issues

As members of the interdisciplinary team, nurses and social workers can help prevent elder abuse and monitor the results of interventions. A nurse, social worker, or both can be appointed as coordinator to ensure that pertinent information is accurately recorded, that relevant parties are contacted and kept informed, and that necessary care is available 24 h/day.

In-service education about elder abuse should be offered to all nurses and social workers annually. In some states (eg, New York), education about child abuse (but not yet about elder abuse) is mandatory for physician, nursing, and social work licensure.

Reporting

All states require that suspected or confirmed abuse in an institution be reported, and most states require that abuse in the home also be reported. All US states have laws protecting and providing services for vulnerable, incapacitated, or disabled adults.

In > 75% of US states, the agency designated to receive abuse reports is the state social service department (Adult Protective Services). In the remaining states, the designated agency is the state unit on aging. For abuse within an institution, the local long-term care ombudsman office should be contacted. Telephone numbers for these agencies and offices in any part of the US can be found by contacting the Eldercare Locator (800-677-1116) or the National Center on Elder Abuse (855-500-3537 or www.ncea.aoa.gov www.ncea.aoa.gov ) and giving the patient’s county and city of residence or zip code. Health care practitioners should know reporting laws and procedures for their own states.

Caregiver issues

Caregivers of a physically or cognitively impaired elderly person may not be able to provide adequate care or may not realize that their behavior sometimes borders on abuse. These caregivers may be so immersed in their caregiving roles that they become socially isolated and lack an objective frame of reference for what constitutes normal caregiving. The deleterious effects of caregiver burden, including depression, an increase in stress-related disorders, and a shrinking social network, are well-documented (see Effects). Physicians need to point out these effects to caregivers. Services to help caregivers include adult day care, respite programs, and home health care.

Prevention

A physician or other health care practitioner may be the only person an abuse victim has contact with other than the perpetrator and should therefore be vigilant for risk factors and signs of abuse. Recognizing high-risk situations can prevent elder abuse—eg, when a frail or cognitively impaired elderly person is being cared for by someone with a history of substance abuse, violence, a psychiatric disorder, or caregiver burden. Physicians should pay particular attention when a frail elderly person (eg, a person with a recent history of stroke or a newly diagnosed condition) is discharged into a precarious home environment. Physicians should also remember that perpetrators and victims may not fit stereotypes.

Elderly people often agree to share their homes with family members who have drug or alcohol problems or serious psychiatric disorders. A family member may have been discharged from a mental or other institution to an elderly person’s home without having been screened for risk of causing abuse. Physicians should therefore counsel elderly patients considering such living arrangements, especially if the relationship was fraught with tension in the past.

Patients can also actively decrease their risk of abuse (eg, by maintaining social relationships, by increasing social and community contacts). They should seek legal advice before signing any documents related to where they live or who makes financial decisions for them.

Resources In This Article

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