(Abuse of Older Adults)
Common types of elder abuse include physical abuse, psychologic abuse, neglect, and financial abuse. Each type may be intentional or unintentional. The perpetrators are often 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 older 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 older person as a child), which encourages the older 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. The National Center on Elder Abuse cites studies reporting as many as 1 in 10 older adults are victims of physical abuse, psychologic abuse, sexual abuse, financial exploitation, and neglect. In Canadian and western European studies, incidence of abuse was comparable to that in the US.
For the victim, risk factors for elder 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—see table Risk Factors for Elder Abuse).
Risk Factors for Elder Abuse
Elder 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 victim often makes detecting elder abuse 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 elder abuse may erroneously be attributed to a chronic disorder (eg, a hip fracture attributed to osteoporosis). However, the following clinical situations are particularly suggestive of 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 older patient alone with a health care practitioner
If elder 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.
The patient should be thoroughly examined, preferably at the first visit, for signs of elder abuse (see table 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
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.
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.
Abused older people are at high risk of death. In a large 13-year 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-year period after abuse was 3 times higher than that for controls over a similar period (1).
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.
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
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.
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 hours a day.
In-service education about elder abuse should be offered to all nurses and social workers annually. In some states, education about child abuse is mandatory for physician, nursing, and social work licensure. However, mandated professional education on elder abuse is established in just a few states.
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 www.eldercare.gov) or the National Center on Elder Abuse (855-500-3537 or www.ncea.acl.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.
Caregivers of a physically or cognitively impaired older 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. Physicians need to point out these effects to caregivers. Services to help caregivers include adult day care, respite programs, and home health care. Families should be referred for such services by using the Eldercare Locator (800-677-1116 or www.eldercare.gov) or the National Association of Area Agencies on Aging (202-872-0888 or www.n4a.org).
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 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 older 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.
Older 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 older person’s home without having been screened for risk of causing abuse. Physicians should therefore counsel patients considering such living arrangements, especially if the relationship was fraught with tension in the past.
Additional considerations should be made for the screening and hiring of in-home helpers, both from formal service agencies and informal private arrangements. A small, but meaningful, proportion of patients who utilize in-home helpers report concerns of theft, neglect, or mistreatment. Screening and training for such workers may help in preventing mistreatment.
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.