Chapter 167. Elder Mistreatment

1. When should you suspect elder mistreatment? What are the signs or red flags?

2. How do you assess for elder mistreatment?

3. What should you document in your assessment?

4. When does a patient require hospital admission?

5. If you suspect elder mistreatment, when must you report it and who should you contact?

6. Which experts are available for consultation?

7. How do you create a safe discharge plan to ensure a smooth transition to the next setting?

Multiple definitions of elder abuse and neglect exist. For practitioners of hospitalist medicine, a useful definition comes from the American Medical Association (AMA), which classifies elder abuse and neglect as “acts of commission or omission that result in harm or threatened harm to the health or welfare of an older adult.”1 This broad description reminds the clinician to look beyond the image of the bruised and battered victim for the often subtle signs of neglect and other types of abuse. Both the World Health Organization and the U.S. National Academy of Sciences definitions add that the “perpetrators” of abuse and neglect are typically persons whom the older adult holds in a position of trust.2,3 These responsible individuals may either cause the mistreatment or fail to prevent it. The AMA emphasizes, however, that mistreatment may be intentional or unintentional. Unintentional mistreatment is often due to a caregiver's ignorance, inexperience, or inability, often stemming from his or her own medical or mental health problems.

Despite the varying definitions of abuse and neglect, agreement exists for the following six types of mistreatment (listed in order of frequency substantiated by Adult Protective Services in the 1998 National Elder Abuse Incidence Study).4

1. Neglect: The refusal or failure of a designated caregiver to meet needs necessary for an older adult's physical and mental well-being. Neglect includes, but is not limited to, the failure to provide basic necessities like food, water, clothing, shelter, and medicine. It also encompasses the failure to ensure an older adult's comfort, safety, and personal hygiene.

2. Self-neglect: The refusal or failure of an older adult to meet his or her own physical and mental needs resulting in threats to personal health or safety. Self-neglect includes, but is not limited to, an elder's failure to take medications, adhere to medical treatment or maintain adequate nutrition, personal hygiene, and shelter. In its most extreme form, self-neglect is manifest by domestic squalor, social withdrawal, hoarding behaviors, lack of shame, and refusal to accept help. While self-neglect is a fundamentally different phenomenon than elder abuse by another actor, hospitalists may confront it even more frequently than elder abuse when neglected health problems cause or contribute to the reasons for hospital admission. Additionally, the same community resources (ie, adult protective services) are often called upon to address self-neglect.

3. Psychological abuse: Verbal or nonverbal acts intended to cause anguish, pain, or distress. Psychological abuse includes, but is not limited to verbal assaults, insults, threats (including threat of abandonment or institutionalization), ...