Chapter 43: Elder Abuse

As hidden as the other forms of family violence may be, domestic elder abuse is even more concealed within our society. As the baby boomers age, the number of elders in the United States will continue to increase. The societal cost for the identification and treatment of elder abuse is also projected to rise as the baby boomers enter the elder years. Elder abuse is now recognized as a pervasive and growing problem. Vastly underreported, for every case of elder abuse and neglect that is reported to authorities, as many as five cases are not reported.

Many physicians feel ill-equipped to address this important social and medical problem. The most common reporters of abuse are family members (17%) and social services agency staff (11%). Physicians reported only 1.4% of the cases. Healthcare professionals consistently underestimate the prevalence of elder abuse. Concerns for patient safety and retaliation by the caregiver, violation of the physician-patient relationship, patient autonomy, confidentiality, and trust issues are quoted as reasons for low reporting. Studies have shown that healthcare professionals attest to viewing cases of suspected elder abuse but yet fail to report them. One study revealed that physicians report only 2% of all suspected cases.

Older victims who suffer from neglect or physical abuse are likely to seek care from their primary care physician or gain entry into the medical care system through an emergency department. Except for the older person’s caregivers, physicians may be the only ones to see an abused elderly patient.

A. Definition and Types of Abuse

Elder abuse encompasses all types of mistreatment and abusive behaviors toward older adults. The mistreatment can be either acts of commission (abuse) or acts of omission (neglect). The National Center on Elder Abuse (NCEA) describes seven different types of elder abuse: physical abuse, sexual abuse, emotional abuse, financial exploitation, neglect, abandonment, and self-neglect (Table 43-1). Self-neglect is defined as the behavior of an elderly person that threatens her/his own health and safety. Labeling a behavior as abusive, neglectful, or exploitative is difficult and can depend on the frequency, duration, intensity, severity, consequences, and cultural context. Currently, state laws define elder abuse and definitions vary considerably from one jurisdiction to another.

B. Prevalence

It is estimated that 4% of adults aged > 65 years are subjected to mistreatment in the United States. In almost 90% of cases the perpetrator of the abuse is known, and in two-thirds of cases the perpetrators are spouses or adult children. Because of underreporting, poor detection, and differing definitions, the true estimate of elder abuse may be far greater. In a nationally representative survey of almost 6000 subjects, the prevalence of elder abuse was 0.6% for sexual abuse, 1.6% for physical abuse, 4.6% for emotional abuse, 5.1% for neglect, and 5.2% for financial abuse by a family. Psychological abuse is more prevalent than physical abuse. Neglect—the failure of a designated caregiver to meet the needs of a dependent elderly person—is the more common form of elder maltreatment. The prevalence of elder financial abuse is difficult to gauge. One researcher estimates that for every known case of financial exploitation, 24 go unreported. Elder self-neglect is an important public health concern that is the most common form of elder abuse and neglect reported to social services.

C. Risk Factors

Several explanations have been proposed to explain the origins of elder mistreatment. These explanations have focused on overburdened or mentally disturbed caregivers, dependent elders, a history of childhood abuse and neglect, and the marginalization of elders in society. Abuse among older adults with cognitive impairment is markedly higher than for unimpaired adults. In a recent systematic review, caregiver burden/stress was a significant risk factor. Care setting also seems to influence risk of elder abuse. Most elder abuse and neglect occur in the home. Paid home care has a relatively high rate of verbal abuse, and assisted-living settings have an unexpectedly high rate of neglect. Moving from paid home care to nursing homes has been shown to more than triple the odds of the elder experiencing neglect. In one study >70% of nursing home staff reported that they had behaved at least once in an abusive or neglectful way toward residents over a one-year period. Risk factors commonly cited for elder mistreatment are listed in Table 43-2.

Characteristics of perpetrators of elder abuse can be seen in Table 43-3.

A typology of abusers has also been suggested to better delineate who may perpetrate abuse. Five types of offenders have been postulated:

1. Overwhelmed offenders are well intentioned and enter caregiving expecting to provide adequate care; however, when the amount of care expected exceeds their comfort level, they lash out verbally or physically.

2. Impaired offenders are well intentioned, but have problems that render them unqualified to provide adequate care. The caregiver may be of advanced age, have physical or mental illness, or have developmental disabilities.

3. Narcissistic offenders are motivated by anticipated personal gain and not the desire to help others. These individuals tend to be socially sophisticated and gain a position of trust over the vulnerable elder. Maltreatment is usually in the form of neglect and financial ­exploitation.

4. Domineering or bullying offenders are motivated by power and control and are prone to outbursts of rage. This abuse may be chronic and multifaceted, including physical, psychological, and even forced sexual coercion.

5. Sadistic offenders derive feelings of power and importance by humiliating, terrifying, and harming others. Signs of this type of abuse include bite, burn, and restraint marks and other signs of physical and sexual assault.

Several medical and social factors make the detection of elder abuse more difficult than other forms of family violence. The elderly dependent patient may fear retaliation from the abuser and may be reluctant to come forward with information. Given the higher prevalence of chronic diseases in older adults, signs and symptoms of mistreatment may be misattributed to chronic disease, leading to “false negatives,” such as fractures that are ascribed to osteoporosis instead of physical assault. Alternatively, sequelae of many chronic diseases may be misattributed to elder mistreatment, creating “false positives,” such as weight loss because of cancer erroneously ascribed to intentional withholding of food.

A. Screening

The US Preventive Services Task Force (USPSTF) found insufficient evidence to recommend for or against routine screening of older adults or their caregivers for elder abuse. The American Medical Association recommends that older patients be asked about family violence even when evidence of such abuse does not appear to exist. A careful history is crucial to determining whether suspected abuse or neglect exists. The physician should interview the patient and caregiver separately, and if the caregiver does not allow this, abuse potential should be considered. A physician’s suspicions should be heightened if the caregiver dominates the medical interview. General questions about feeling safe at home and who prepares meals and handles finances can open the door to more specific questions. Ask if the caregiver is yelling or hitting, making the elder wait for meals and medications, confining the elder to a room, or threatening institutionalization. It is also important to inquire about the possibility of sexual abuse (unwanted touching) or financial abuse (stolen money, being coerced to sign legal documents without understanding the consequences). Self-neglect may be present if the patient begins to miss appointments, gets lost on the way to appointments, or is unable to take medications correctly. Table 43-4 lists important questions to ask when screening for suspected abuse.

Avoid confrontation and blame when interviewing the caregiver. Ask about caregiver burden. Be alert if a caregiver has poor knowledge of a patient’s medical problems. If a caregiver has excessive concerns about costs or is financially dependent on the elder, be alert for financial abuse. A study of 2800 older adults found that elder mistreatment was associated with an increased risk for nursing home placement and all-cause mortality. Self-neglect is associated with increased rates of hospitalization and mortality as well.

B. Physical Examination

There are no pathognomonic signs of elder abuse, and physical abuse is not the most common type of elder abuse. Yet a thorough physical examination is critical as the elder victim may not be forthcoming about the abuse. Particular attention to the functional and cognitive status of the elder is important to understanding the degree of dependence that the elder may have. Neglect or self-neglect should be suspected when a patient appears disheveled or has evidence of poor hygiene. Table 43-5 lists findings suggestive of physical abuse.

Detailed documentation of the physical examination is important as it may be used as evidence in a criminal trial. Documentation must be complete and legible, with accurate descriptions and annotations on sketches or, when possible, with the use of photographic documentation.

Barriers to reporting elder abuse are listed in Table 43-6. Forty-four US states have mandatory reporting laws that require healthcare professionals to report a reasonable suspicion of abuse or self-neglect. Most states have anonymous reporting and Good Samaritan laws that can offer an alternative to a direct physician report if there are significant concerns for maintaining the physician-patient relationship. By emphasizing the treatment of the health consequences of the abuse, the elderly patient and caregiver may feel less threatened. Reporting should be done in a caring and ­compassionate manner in order to protect the autonomy and self-worth of the elder while ensuring his/her continued safety.

The victim should be told that a referral will be made to Adult Protective Services (APS). Involving the caregiver in the discussion must be carefully considered with regard to potential retaliation on the victim. The law enforcement implications of APS should be downplayed, and the social support and services offered by APS should be offered as part of the medical management of the victim. Victims may deny the possibility of abuse or fail to recognize its threat to their personal safety. In financial abuse the victim, the offender, or both may not acknowledge the abuse. If the victim refuses the APS referral, the clinician may explain that s/he is bound to adhere to state regulations and that the regulations were developed to help older persons who were not receiving the care they needed.

The safety of the patient is the most important consideration in any case of suspected abuse. If the abuse is felt to be escalating, as may occur with physical abuse, law enforcement as well as APS should be contacted. Hospitalization of the elder may be a temporary solution to removing the victim from the abuser.

If elders have decision-making capacity, their wishes to either accept interventions for suspected abuse or refuse those interventions must be respected. If an abused elder refuses to leave an abusive environment, the primary care physician can still help. This may include helping the older victim to develop a safety plan, such as when to call 911, or installing a lifeline emergency alert system. Close follow-up should be offered.

If older victims no longer retain decision-making capacity, the courts may need to appoint a guardian or conservator to make decisions about living arrangements, finances, and care. This is typically coordinated through APS. The physician’s role is to provide documentation of impaired decision-making capacity and of the findings of abuse.

Intervention can be complicated when self-neglect is suspected. Patients may be capable of understanding their actions even if their choices disagree with recommendations of family or professionals. Assessment of cognition and decision-making capacity are critical and may be challenging if individuals refuse assessment. Behavioral health professionals, ethics committees, the guardianship process, and court system are invaluable in assisting families and ­physicians. Because of confidentiality guidelines it may be difficult to enlist clergy and other community organizations for help.

As the size of the elderly population continues to grow, physicians need to be vigilant in identifying patients at risk for elder abuse. The physician’s role is to recognize elder abuse and self-neglect, treat any associated medical problems, and provide a safe disposition for the patient.